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CLINICAL LECTURES

SURGERY,

DELIVERED AT THE HOSPITAL OF LA OHARITfi.

L. G08SBLIN,

TRANSLATED FROM THE FRENCH

LEWIS A. STIMSON, M.D.,

WITH TWENTV-ONE FLLUSTRATIONS.

PHILADELPHIA:

HENKT O. LEA.
1878.

. ♦

J'*' y

Entered according to the Act of Congress, in the year 1878, by

HENRY C. LEA,
in the OflSice of the Librarian of Congress. All rights reserved.

• • •

• * • •••

• • • •

• • ••:

• • •

•• ••

• • • •

• • • > •

• • •

PHILADELPHIA:
OOLLIKB, PRINTER,

705 Jayne Street.

PREFACE.

The lectures oF which these are a part were delivered by Professor
Goaaelin during the first five years following bia advancement to th*
position occupied ao long by Velpeau. The surgical servicQ of I*''
Chants, which for more than two hundred years has been connected
with medical instruction at Paris, now belongs to the ranking chair

Clinical Surgery in the ficole de Medecine, and a position in one
of its three wards is the prize awarded each year to the student who
passes the best examination for the internat. Professor Gosselin
himself, after having risen through all the subordinate positions, and
having gained each promotion by a competitivo examination, stands
DOW, since the death of Velpeau, at the head of the surgical section of
the Faculty.

In the preface to the first edition of his lectures, Professor Gosselin '
has explained the three motives which led to their publication. The
first was the desire to exemplify his conception of the proper method
of clinical instruction, that in which a patient is taken as the text of a
lecture in which everything relating to the etiology, symptomatology,
prognosis, and treatment of the affection is properly developed and
illustrated, ao far as possible, by the patient himself. The second was
to show to what extent the acquisitions of modern scientific research
are applicable to the treatment of disease; and the third, to publiaU'
his own original opinions upon certain questions, especially those
had not treated of in previous works.

In making a selection of the Jectures for translation the choice was
guided by two considerations: 1st, to take those which would be moat
serviceable and of the greatest interest to the profession in America ;
arid, 20, to take those upon subjects with which the author is ma-fsi

:wo.-i«y

IV PREFACE.

particularly identified, those in which he has done much original and
valuable work. Among the latter may be especially mentioned the
study of the diflferent forms of osteitis, of certain forms of arthritis,
of the ultimate results of fracture of the limbs, and of the influence
of adolescence upon the pathogeny and prognosis of certain affections.
The only important deviation from the original arrangement occurs
in Part IV., which is made up of a section upon Surgical Septicaemia,
and of two lectures taken from a section upon Gunshot Wounds.

The translation was made in Paris, during a prolonged service in
Professor Gosselin's wards, and contains several corrections and
revisions made for it by him. It is hoped that the opportunities
thus afforded have insured an exact rendering of the author's thoughts.

LEWIS A. STIMSON.

New York, June, 1878.

ERRATA.

Page 153, 13th liue from top, for with read without.
" 172, 11th " " bottom, for an read no,
" 220, 1st " " top, for esteo- read osteo-.

CONTENTS.

PAET L

SURGICAL DISEASES OF YOUTH.

Lectdrb page

I. Ingrown Toe-nail and its Treatment 1

II. Sub-ungaal Exostosis of the Great Toe 9

III. Non-specific Epiphysary Exostosis of Youth or Exostosis of Development 14

IV. Suffocating and Rebellious Naso-pharyngeal Fibroma or Fibrous Polyp
V. Two Cases of Subacute Non-suppurating Epiphysary Osteitis .

VI. I. Hyperostosis of Right Femur. II. Necrosis of Left Tibia .

VII. Acute Epiphysary Osteitis of the Left Femur, with Suppurating Arthritis
of the Knee. Amputation of the Thigh .....

VIII. Tarsalgia of Adolescents. — (First, Second, and Third Degrees)

18
31
36

45
51

PAET II.

FRACTURES OF THE LIMBS.

Lecture

IX. Anatomical and Clinical Phenomena of Consolidation after Fracture of

Long, Flat, and Short Bones . . , 60

X. Phenomena of Consolidation after Compound Suppurating Fractures . 75

XI. Fractures of the Leg 78

XII. Fractures of the Leg — continued . .90

XIII. Compound Fractures of the Lower Third of the Leg .... 101

XIV. Fractures of the Leg 112

XV. Bi-malleolar and Supra-malleolar Fractures of the Leg . . . .116

XVI. Consecutive and Late Phenomena of Simple Fractures of the Leg . 124

XVn. Fractures of the Leg 131

XVIIL Fractures of the Patella 136

XIX. Fractures of the Patella — continued 141

XX. Simple Fractures of the Shaft of the Femur 155

XXI. Fractures of the Neck of the Femur 167

XXII. Fractures of the Lower Extremity of the Femur t^^

■»

VI CONTENTS.

Lbcturb paob

XXIII. Spontaneous Fractures, and Iterative Fractures of the Shaft of the Femur 187

XXIV. Fractures of the Lower Extremity of the Radius ... . . .193

XXV. Fractures of the Lower Extremity of the Radius— continued . .198

XXVI. Fracture of the Clavicle by Muscular Action 205

PAET III.

TRAUMATIC OSTEITIS AND NECROSIS.
Lecture

XXVII. Traumatic Osteitis of Long Bones 211

XXVIII. Necrosis of the Long Bones 217

PAET lY.

TRAUMATIC FEVER, PYEMIA, AND SEPTICEMIA.
Lectubb
XXIX. Traumatic Fever 227

XXX. Purulent Infection or Pyaemia 236

XXXI. Etiology of Surgical Septicaemia 253

XXXII. Treatment and Prophylaxis of Surgical Septicaemia .... 2G0

PAET Y.

DISEASES OF THE ARTICULATIONS.
Lecture

XXXIII. Diagnosis of traumatic Dislocations 275

XXXIV. Traumatic Arthritis of the Knee 284

XXXV. Acute and Subacute Spontaneous Arthritis of the Knee . . . 290

XXXVI. Chronic Arthrites of Ihe Knee — Hydrarthrosis .... 298

XXXVII. Chronic Arthrites of the Knee, continued. — Fungoid Arthritis or

White Swelling 304

XXXVIII. Dry Arthritis of the Knee 314

XXXIX. General Considerations upon Arthritis in the other Articulations . 322

PAET YL

PHLEGMONS, ABSCESS, FISTULA.
Lectdbe
XL. Abscesses of the Hand Consecutive to Synovitis of tho Flexor Tendons . 327

XLI. Superficial and Deep Diffuse Phlegmon of the Forearm .... 332

XLII. Dental Abscesses and Fistulse . . 338

CLINICAL LECTURES

SURGERY.

PART I.

STTRGICAL DISEASES OF YOUTH.

LECTURE I.

maSOWN TOE-NdIL AND ITS TREATMENT.

Rterstfona upon the diaeaaes of youth — Dia
semilanar anyahiit, and snb-uD^al onycbii
growD toe-oail — Etiology — Inflnttnus of nge, :
geuBfal oaasfl — Treatment — Local an mat has id

lotion between lateral onychia,
-Origin of lateral onychia or in-
lial position, aei, iiiappreoiablo
' means of ice and salt.

Gkntlbmkn: I never fail, whenever the occaaion presents itself,
' call your attention to the influence exerted by age upon the develop^"
meat, course, and prognosis of surgical diseases, and the consequences
of the operations necessitated by them.

The surgical pathology of childhood has already been made the
subject of special studies, and if that of old age has not been treated
of in separate works, yet our authors have not omitted to mention
whatever there ia of importance in its relations with the diseases of
each organ and system.

In moat of the descriptions which have been handed down to ne;
the classical authors have taken the adult age as the type. Thei '
have noted certain details peculiar to infancy and old age, but
forgotten the period oF adolescence, the limits of which, without being
rigorously determined, lie between the a^es of 15 and 25 years, a
period In which occur the development of puberty and the comple-
tion, sometimes rapid and irregular, of the growth of the skeleton.

I do not claim that this age ia exposed to diseases which are devel-
oped during no other. I know, on the contrary, and I shall oftei.
^iiive oouaaioQ to tell you, that most of those of vj\\\iJc\ \\, aSax* e,-i%.'is\';J\'ea

oar -^^

2 SURGICAL DISEASES OF YOUTH.

are quite frequent in childhood, and that some are also seen in the
adult. I claim only that certain diseases are notably more frequent
during youth than at other ages, and that the prognosis and treatment
are thereby affected to an extent which our predecessors did not notice,
and upon which my attention has been fixed for a certain number of
years.

I shall presently operate before you upon a young man 16 years
old, who offers you an example of one of the diseases of youth, an
ingrown toe-nail.

His history, in brief, is this : His constitution is good, and he has not
recently had any serious disease. For the last two years he has been
employed in a pastry-cook shop, and compelled to remain on his feet
a great part of the day. Four months ago he noticed an excoriation
at the outer side of the nail of the great toe of the left foot. He took
no care of it, and continued to walk. But the excoriation increased ;
and, as it was lodged in the cutaneous groove which receives the edge
of the nail, it is probable that it was kept open by the irritation con-
stantly excited in it by this edge. The oozing grew more and more
abundant, and the sore at last became the seat of smarting pains,
which were more severe in the evening. Suppuration also increased
when the patient had walked all day. When he woke in the morn-
ing, the pain and swelling were very moderate. On different occa-
sions the swelling increased, was accompanied by a redness which
spread over the dorsal surface of the toe, and the patient was com-
pelled to keep the bed for twenty-four hours. Another time the red-
ness was accompanied by a little fever, and appears to have assumed
the character of an angeioleucitis. No serious treatment has been
given it ; and the young man, after another exacerbation which com-
pelled him to stop his work, decided to ask us for the attentions neces-
sary to a complete cure.

I shall say no more about the functional symptoms; they are those
of which I have juwSt spoken. They are light, are accompanied by
no alteration of important functions, and might have been borne much
longer were it not that they interfered with his walking and thus pre-
vented the exercise of his calling.

As to the physical symptoms, they also are very simple; you have
noticed them when comparing the left toe with the right one, which
is healthy. They consist in a rather hard and, as it were, hypertrophied
swelling of the cutaneous rim which is found at the outer side of the
nail, and in the existence of a narrow solution of continuity, elonga-
ted, granulating, reddish, and suppurating, which occupies the entire
depth and the anterior two- thirds of the lateral groove corresponding
to the edge of the nail. As there is some tumefaction, this groove is
deeper than usual. Pushing aside the cutaneous rim, we see that the
small vegetating wound extends not only to the bottom of the groove,
but also around the edge of the nail, and is continued under it, if not
throughout its whole extent, at least over that portion where the at-
tachments of the nail to the skin are not very firm; and this portion
is larger than usual, because the ulceration has destroyed part of the
skin which established the connection.

IKGROWN TOB-NAIL ANn ITS TRBATMENT.

There is no doubt aa to the diagnosis: we have here to denl with
the disease described under the name of ingrown toenail, one which I
Bometimes call lateral ukerated onychia, in distinction from two other
rarer varieties: semilunar ulcerated onychia (extending ail around
the nail), and subungual ulcerated onychia. The term ulcerated
onychia has the advantage of denoting that it is not the nail which ia
diseased, that it is the neighbouring akin which has been excoriated,
and that this excoriation is kept up hy the edge of the nail, which
nets upon it as a foreign body. I wish I could lell you exactly how
the ulceration begins in such a case, and especially how it began in
the ease of this young man. But T have never had the opportunity
to see the beginning. It may be that it is simply traumatic, the akin
which corresponds to the edge of the nail having been cut at a certain
moment by this edge, either naturally sharp, or rendered so by care-
leaa trimming of the nail, which in addition may have brought the
edge against a part of the akin which is thinner and less protected by
the epidermis than those portions which are normally in contact with it.

It may alao be that the origin is pathological, that it may have
begun in a moist erythema or slight herpes aggravated and ulcerated
by the pressure of the edge of the nail, I have been consulted by
two patients who had had for a few days the slight skin disease which
J have juat mentioned. T made them keep the room, take a warm
foot-bath, and place, morning and evening, some aubnitrate of bismuth
in the groove of the nail. In a few days the disease disappeared; but
1 have asked myself whether, if no care had been taken, and if the
patients had continued to walk, it might not have ended in an in-
grown nail.

Whichever of these may be the origin, we can still draw two eon-.
elusions to direct the prophylaxis : the first ia that we must advise
every one, and especially adolescents, for they are chiefly exposed to
fthis trouble, not to cut off that part of the nail which covers the sub-
pongual eutiole, or, if you prefer, not to carry the section beyond the
epidermic adhesions of the border of the nail, so as not to bring this
border, made a little sharper by the trimming, into contact with a-
part of the akin which is thin and unprovided with epidermis. The-
second is that pressure from below upwards, while walking, forces
the already more or leas altered skin against this edge, and that con-
sequently rest is necessary to increase the chances of a cure when the
patient decides not to undergo an operation.

But if we are not quite sure of the anatomical pathogeny of the
■ingrown toe-nail, we know very well the conditions which favour its
development and act aa predisposing causes. These conditiona, whicH
liave certainly affected our patient, are three in number: age, social
position, and sex,

1. Age. — The patient is IR years old. You may think it is only
■chance which has given us this occasion to see an ingrown toe-nail
Tipon a person of this age. No; on the contrary, it ia very commoai
in adolescents. For the last ten yeara I have kept a record of all the

I
I

4 SURGICAL DISEASES OF YOUTH.

cases of incurvatioQ of the nail of the great toe^ which I have treated.
Fifty-four of these were upon boys (I will speak of the girls in a
moment), and are thus grouped according to the ages.

T saw none before the age of 14 years. I do not claim that it does
not exist, but I believe it to be very rare. My table begins at 14J
years : —

.ienl

bs 14^ and 15 years of age .

Patients 23

. 2

16 . . . .

. 12

. 1

. 8

. 2

1 .

. 6

. 1

I . i

. 1

> . <

. 7

. 2

•

. 2

> •

. 2

You see then that from 14 J to 20 years we have 41 cases; from 21
to 25 years 9 cases; from 2b to 80 years 4 cases. It must also be
noted that in one of my two patients aged 80 years, the disease began
when he was only 18 years old. I was right then in telling you that
adolescence predisposes to this disease.

But how explain this influence of age? I do not hide from you
that this is a difficulty which we shall encounter in some of the other
diseases of youth. I suppose we must consider it due to rapid growth,
in consequence of which the nail becomes a little too large for the
surrounding skin, or, the toe being compressed in shoes which have
become too small, the edge of the nail is pressed too firmly against
the cutaneous fold. You see, gentlemen, I do not exclude the other
local causes, just as I admitted a moment ago the possible intervention
of general ones. But the existing local causes, the rapid growth of
the nail, the lengthening of the foot, pressure upon it by shoes that
have become too small, enable us to understand why incurvation of
the nail is more likely to occur during the period of growth than at
any other time.

2. Social Position. — My 54 patients belonged to my hospital practice.
In private practice I have treated only two young men for ingrown
toe-nail. This is doubtless due to the fact that youths of the labour-
ing classes take less care of themselves at the beginning, walk and
fatigue themselves more, and, above all, do not supply themselves soon
enough, when growing rapidly, with new shoes in which the toe would
have more room.

8. Sex, — Its influence is proved again by figures. During the ten
years I have treated in all ten women, seven of them in the hospital,
three in private practice. As in the case of the males, here too we see
the influence of adolescence, for eight of my patients were between the
ages of 15 and 22.

1 was

•

15 years old.

1 was

19 years old.

2 .

•

16 " "

2 .

22 " "

2 .

•

17 " "

Of the last two, one was 80 years old, but the disease began at the
age of 18 years ; the other was 43 years old.

* Ingrown toe-nail occurs much more rarely on tlie other toes, and is then due to
a general rather than to local causes. I speak now only of that of the great toe.

INGROWN TOR-NAIL AND ITS THBATMBNT.

Tf you ask me wliy growing girls are less exposed to ingrown toe-
nnil than boys are, I answer, without, however, being too affirmative on
this point, that I attribute it to this, that in general girla walk and
fatigue themselves les3, take rather better care of themselves, and do
not so often grow rapidly.

But must we not also admit some general cause in this etiolojjy ?
Let me explain. There are appreciable general causes, and others
■which are inappreciable, I have found more of the former in the 64
eases which I have treated. Tou have heard me apeak aometimcs of
syphilitic onychia. But you notice, or yon will notice hereafter, that
in such cases the ulceration, instead of being limited to the edge of the
nail, extends all around the matrix and aometimes to the sub-ungual
dermis; also that the great toe is not alone affected, the others are
attacked at the same time. In the real ingrown toe-nail, that of youth,
the disease occupies exclusively the lateral border of the nail and the
great toe. I should also tell you that it is much more frequent on the
outer' than on the inner side, and that when it occupies the latter the
former is almost always affected at the same time. In the statialica
which T have carefully kept on this point, I find the inner aide alone
affected only three times, both aides of the same nail four times, and
in the forty-seven other cases the outer side alone.

As to the other general cause which we meet with so often in the
diseases of youth as well as in those of infancy, scrofula, I have had
no reason to think it has affected my patients.

There remain then the inappreciable general causes. Without de-
fining them, we are obliged to admit their influence in many diseases ;
it is likewise probable that they exist in this one. This will explain
the occasional development of an iuj^rowa toe naii during adult life,
that is to say during a period when the predisposing causes of which
I have spoken exist to a much less degree or not at all, alao why in
certain youths both sides of the nail are affected, and in others both
feet either at the same time or aucceaaively. I have occasionally seen
ingrown toe-nail, appear, sometimes on the great toe, sometimes on
one of the others, during convalescence after an acute disease or in
the course of a chronic one, under conditions, in short, where it was
impossible to lay it to the charge either of growth, or walking, or eveu
the fatigue of standing. These cases are not included in my statistics,
I attribute them to one of these inappreciable and unnamed general
causea, and in any case they deserve separate study, since their treat-
ment should not be the same, and an operation should be considered
useless and even dangerous.

This slight affection is certainly not serious, since it compromises
neither health nor life. It has only the inconvenience of making it
painful to walk and thereby interfering with the business of those who
gain their livelihood by walking or standing most of the day. An-
other peculiarity, and one which has especially interested the surgeons,
IB its tendency to return, even after surioijs operations, but the notions

' Rererring to the media

SURGICAL DISEASBB OF YOUTH,

Hrhich T have given you upon the iTifluence of Eige diminish greatly ■
tfee irnportunce of this fact, Tlie ingrown nail of youths may return,
Itut only during the perioil of life which predisposes to it. Youth
jtOnce passed, the trouhle does not return after trentrnent. Suppoae '
"then, that, in spite of your cure, one or two relapses take place while
jour patient is between 16 and 22 years of age. After that time you
anay be sure the trouble will not re-appear. Moreover, we posseaa

jans which protect even the adolescent from a return of the aftiiction.

Treatment. — There are few surgical diseases for which so many
local ireatmenta have been proposed. I have counted as many as
seventy-five of them, all suggested by honourable surgeons moved by
the desire to protect the piitienta from relapses; they had not learned
that relapses cease witli the period of youth. Of these means, some
are simple, and consist of dressings repeated once or twice each day;
others, of partial or complete extraction of the nail ; others, of varied
and complicated operations with the knife or caustics, generally
supplemented by the extraction of more or less of the nail, T shall '
describe only the three principal methods and the two or three pro-
cesses to which I advise you to give the preference in your practice.

Ibt Method. Dressings. — This method, to which I attach the name
of Fabrizio d'Aquapendente, an Italian surgeon of the IBth century
who wrote a large work on surgery, consists in interposing belweea
the nail and the ulceration a foreign body, which separates them from
other and prevents the second from being continually irritated
'Shy the first. For this purpose Fabrizio used lint, as we do also to-day.

A few months ago you saw me treat in this way a woman who
came every other day to the consultation, and who for various reasons
was not willing to allow the nail to be lorn out. I passed every time
with a spatula a few threads of lint under the outer edge of the nail.
I took pains to press it past the edge and well under the nail, and
then completed the dressing wiih another pad of lint, which I placed
on the upper surface of the corresponding cutaneous ridge, and kept
in place by means of a strip of diachylon pliLster wrapped two or three
, limes around the toe so as to press the pad well under the ridge.
After six weeks, during which this dressing was renewed every other
(lay, the ulceration was oicatri?,ed, the tumel.iction about it diminished,
and the edge of the nail sufficiently separated from its cutaneous
groove. I told the patient to wear broad shoes and not to cut the
nail short, especially on the outer side. Since then I have not seen
her, but have heard that there has been no return of the trouble.

Instead of lint you may use a atrip of tin (Desauli) ; or of lead
(Boyer) ; or even of cork.

I advise you, gentlemen, to familiarize yourselves with one of these"
dresaings, and, in my opinion, the simplest is the one with lint. Yoa
may have occasion to use it in the earlier stages, or in the later one3
when the patients have the time to take care of themselves, andare
able to remain six or eight weeks without walking, or walkjng but
little. For this interposition of a foreign body is not easily borne
when the pressure upwards, which is produced by walking or standing,

INGROWS TOa-NAlL AND ITS TKEATMENT.

I
I
I

constantly forces tbe inBamed nkin asainatit; and, although not so
sharp and irritating as the edge of the nail, it is still In a certain
measure a cause of irritation.

I have not thoui^ht of employing this treatment for this patient,
because it requires too much time, and becnuae confinement to the
bed or to the room is undesirable at his age, I may also add that
these dressings have the inconvenience of being quite painful at the
moment of application and for an hour or two thereafter. And, finally,
this mode of treatment is one of those which expose the most to a re-
turn of the trouble. You will see it succeed on persons in easy cir-
cumstances, especially women, who not only can give themselves the
needed time and rest, but, once cured, can favour themselves and walk
but little. Our young man, on the contrary, is obliged to gain his living
by his legs, and as soon as he is cured he will have to begin at once
to wiillt, so that the chances of an early return of the affection would
be great.

'in Method. Simple Extraction. — This operation, which is applied
sometimes to the whole of the nail, sometimes only to the half which
is ingrown, is intended to remove the body whifh acts as an irritant,
and give the little fungoid ulceration time to heal. Of course, the
nail grtfwa again, for in removing it we do not destroy that portion of
the skin which produces it, and notnhly the deep posterior fold called
the mntrix. I will describe in a moment the method of extraction
which I prefer, before performing the combined operation of which it
forms part.

This method has the real advantage that it can be performed with-
out pain, and is followed by a prompt cure, for at the end of five or
six days, during which rest and a protecting dressing alone are needed,
the raw surface has become dry and the ulceration healed. But, un-
fortunately, it is often followed by a return of the trouble. T cannot
give the exact figures, bat I remember to have seen in the service of
Velpeau a certain number of patients who returned at short intervals
to undergo the operation a second, third, or fourth time. As I have
already told you, I know that after a while adolescence ends, and
with it the tendency to the reproduction of the disease; but still it is
an inconvenience which we should seek to avoid as much as possible,
and in this respect the combined operations are a little more successful.

3d Method. Combined O/ieralions — These are the ones by which it
is proposed to remove both the edge of the nail and the cutaneous ridge
upon which the fungoid granulations are found. For this purpose
Bome authors have recommeded caustics; others have combined ex-
traction of the nail with excision of the fleshy parts. To this last
operation I give the preference, but, after tearing out the nail, I cut off
only a portion of the ridge, so as to have a wound which is smaller,
will cicatrize more promptly, and is less likely to give rise to erysipelas
or angeioleuciiia, and, moreover, is sufficiently removed from the
articulation of the two phalanges to avoid the chances of provoking
suppurative arthritis. I propose, also, to remove on the altected aide
a considerable [lortion of the matrix, so that the new uail may be much

SCRQIOAL DISEASES OF YOUTH.

^1 earrower than the old one. You understand that this reduction of |
^g the breadth of the nail diminishes the ohaocea of a relapse, which are J
greater the nearer the eilge of the nail ia to the bottom of the grooves
in which it lies. I have several times measured the new nail a few I
months after this operation, and have always found it narrower than l
that of the other I'oot. I have already published my method (^ j
performing this operation,' and I shall now execute it before you ia 3
the following manner: — 1

1st Time. — To prevent pain I shall make use of a freezing mixture j
.composed of equal parts of pounded ice and salt. The mixture will ]
■ ibe made just before it ia to be applied, and will be plarad in a small |
bag made of thin muslin. I shall place this bag upon the dorsal sur-
fece and the sides of the great toe, cover it with a compress, and leav^
it it) place for two minutes, when I shall remove it to see if antesthe-
Bia has been obtained. If I find the skin still red and sensitive I
shall re-apply the mixture and leave it until sensibility is entirely
deadened.

I recommend this mode of antesthesia in this operation, because^ l
aince the parts upon which we are to operate are superficial, it ia use- I
■less to seek to dull the sensibility of the deeper ones, as we have to J
do when our indsions are carried beyond the limits of the akin, and ]
oonaequently we are not embarrassed by the pre occupations of gene* 1
i-al atiEeatheaia produced by inhalation. Local anassihesia may be ob- ]
tained by refrigeration with ether, but this process requires more time ]
and does not produce so complete a result; and as the operation we
Bse to perform ia very painful, we must deaden sensibility as com-
pletely aa possible.

2d Time. — Standing at the foot of the bed, and at the affected side^
and having seized the toe firmly with my left hand. I shall pass one
of the blades of a strong pair of scissors on its side under the nail !
aa far back as the matrix, then turning the edge upwards, and closing j
the scissors quickly, I shall divide the nail lengthwise into two equw I
parts. Then with a stout pair of forceps I shall seize each piece in
turn and tear it out. Sometimes the nail is friable and breaks; thea
of course the fragments must be successively removed. Do not forget
that for this purpose you need a very strong pair of forceps, one
B blades will not twist under the violent effort you will have to

Pwuusu oiuiics will uub bwi»b uuuci LUC V luitiii ii eiiu] I, you win nave lu ^^h
make. ^^1

Zd Time. — This consists in the excision of a strip of skin, leaving a ^^|
wound which, though small, comprises in front a portion of the outao ^^H
neous ridge and abnormal vegetations, and behind the external lateral ^^H
portion of the matrix. For this I shall take a bistoury, and make^ ^^H
behind, at the junction of the transverse and lateral portions of the ^^|

I matrix, a tranaverae incision oue-quarler of an inch long through the ^^
• ■■■'■■ .-.■■-. ■• . .

BUB-L'NQUAL EXOSTOSIS OF THE GREAT TOE

( dissect inwards the flap thus formeil, so as to include in it the entire
length and thickness of the sub-ungual dermis for a breadth of nearly
one-quarter of an iuuh, that is, its a utero -lateral portion and the cor;-
responding piece of the posterior portion or matrix.

I shall fiaish with a protective dressing made of a cloth c
■with cerate, lint, compresses, and a narrow band. This dressing will
be renewed every day for eight or ten days, at the end of which time
the patient will be able to leave his bed, and perhaps the hospital.

During the last year you have seen me treat several patients in this
way. In no case did any complication occur. In all the little wound
healed, and the dermi.B dried in a length of time which varied from
eight to fifteen days. When the patients left us they had no nail, but
they could wear a shoe and walk by placing a rag or a little carded
I cotton over the toe. In only one of my sixty-four cases was the cure
delayed by an angeioleucitis of the foot and leg, followed by small
. inuUiple abscesses along the eourse of the lymphatic vessels, and -
I although delayed the cure was still obtained. _

Upon none of the patients whom we have had this year have we &t9
yet seen any return of the affection. Hut I have already told yott i
that my method, although it removes the ulcerated skin uod dimin-
ishes the breadth of the nail, still does not always prevent a rdapse.
In only five of my sixty-four cases has the disease returned, three
boys and two girls, but I have had no example of a second return,
J Consequently the jnost unlucky have had to undergo the operation
I only twice. I have seen again several of them who had then passed

I the age of 25 years^and in whom the affection had not returned, and

I I have yet to sue a relapse in any of niy patients who have paatied the
liperiod of youth.

LECTURE II.

BUB-ONGUAL EXOSTOSIS OF TilB GREAT TOE.

d sjmpton

— Diagnoaia — Importance of age and i
aesse of yontl!, more common iu giria than in bnys — Anatomiflal olmrStf-l
teristias — Analogf to epiphyaary exostnaia, and to naso-ptiRrjngeal polypa-^1
Traatmeut — I'o^lbla relapstt — CussatioD of this teudenoy after adolesaanae.

Gentlemen; I have here a small piece which I removed the claj'^^
I iwfore yesterday in your presence from the gret(t toe of a girl 20 years (J
, old. She was a dressmaker who had been admitted into the hospi-
i tal a few days before to be treated for a tumour as large as a small nut
Occupying the interior and superior surface of the left great toa ^\. \Na

6 8DRG1CAL DISKA3B9 OP TOOTH.

which T have given you upon the influence of nge diminish greatly
the importance of this fact. The ingrown nail of youths maj returo,
but only during the perici of life which pre(li3po!»ea to it. Youth
once passed, the trouble does not return after treatment. Suppose
then, that, in spite of your cure, one or two relapses take place while
your patient ia between 16 and 22 years of age. After that time you
may be sure the trouble will not re-appear. Moreover, we possess
means which protect even the adolescent from a return of the affection.

Trealment.— There are few surgical diseases for which so many
local treatments have been proposed. I have cimnted as many as
seventy-five of them, all suggested by honourable surgeons moved by
the desire to protect the patients from relapses ; they had not learned
that relapses eeaae with the period of youth. Of these means, some
are simple, and consist of dressings repeated once or twice each day;
others, of partial or complete extraction of the nail ; others, of varied
and complicated operations with the knife or caustics, generally
supplemented by the extraction of more or less of the nail- ' shall
describe only the three principal methods and the two or three pro-
cesses to which I advise you to give the preference in your practice.

1st Method. Dressings.— Thia metliod, to which T attach the name
of FabrizJo d'A(juapendente, an Italian surgeon of the IBth century
who wrote a large work on surgery, consists in interposing between
the nail and the ulceration a foreign body, which separates them from
one another and prevents the second from being continually irriuted
by the first. For this purpose Fabrizio used lint, as we do also to-day.

A few months ago you saw me treat in this way a woman who
came every other day to the consultation, and who for various reasons
was not willing to allow the nail to be torn out. I passed every time
with a apatulu a few threads of lint under the outer edge of the nail.
I took pains to press it past the edge and well under the nail, and
then completed the dressing with another pad of lint, which I p'aw"
on the upper surface of the corresponding cutnneous ridge, and kept
in place by means of a strip of diachylon plaster wrapped two or three
times around the toe so as to press the pad well under the ridge.
After SIX weeks, during which this dressing was renewed every oth«
day, the ulceration was cicatrized, the tumelaction about it diminiai'^T
and the ^ge of the nail sulTiciently separated from its cutaneOfflf
groove. I told the patient to wear broad shoes and not to cut tea
nail short, especially on the outer si.le. Since then I have not 998^
her, but have heard that there has been no return of the trouble. *-i'

Instead of Imt you may use a strip of tin (Desault); or of WW ,
(Boyer) ; or even of cork.

I advise you, gentlemen, to familiarize yourselves with OT^
dressings, and, in my opinion, the simplest is the ona '*^
may Have occasion to use it in the earlier stages, or
when the patients have the time to take cart of ll
1W.1 tT""";" ^'^ ""^ ^'S'lt weeks without walkil
little, tor this interposition of a foreign body '
when the pressure upwards, which is produced bf

aUB-CNerAL KX09TOSI3 OF TB

[

But I rejected siicli an opinion, niid admitted iiQ exostosis. Cor the

The Age. — Altliough I liave seen an example of sob-UTipvial :
■flxostosis in a woman il years old, it ia none the less truR that thin,
iike ingrown toe nail, is a disease of youth, Dupuytren, who was the '
in France to give a clear and methodical description of this afF
reports five cases in which the patients were from 20 to 25 yeara ]
but in all of them the disease began at about the age of 18. ■
puytren, however, although mentioning the age of each of his ^
batients, did not call attention to this fact. Legoupll,' on the othei
hand, clearly points out adolescence as one of the principal predis* J
posing causes, for, he says, "most of the cases within my knowledge' 1
are confined between the ages of 15 and 20, and 1 found none who *
had passed their 2fiih year." It is certain that Legoupil speaks not '
of eases which he had himself observed, but of those which he found
recorded, and, indeed, it is incontestable that almost all such beloi
to the end of the period of adolescence, although the authors do not
call attention to this fact. Still it is easy to understand how thia
etiological idea may have escaped the notice of many persona. Sub-
ungual exostosis is rare, and each surgeon, having seen only a few
examples, and having seen them only at long intervals, may have
Considered the similarity of age as the result of chance. As for me»
I have preserved the record of only eight patients. Seven of thesa'
were aged as follows : two, 19 years old ; two, 20 ; one, 21 ; one, 24 ;
and one, 25 ; but in all the disease commenced one or two years before
I saw them for the first time. I said just now that I had had one \
patient 47 years old ; that proves thai this, like ingrown toe-nail, may
be developed in the adult; but it is exceptional, and we may consider
it the rule that sub-ungnal exostosis is a disease of y

2d, Sex. — Our patient was a young girl. Now, the analysis of the'
sea shows that, unlike ingrown toe-nail, this affection is more com-
mon among girls than among boys, Dupuytren's five cases were all
girls. Legoupil points out that the ten ca-'fea of which he knew were
all yonng girls. Of mine, five were girls, three were boys. Althoagb
in the printed records you find girls mentioned more often than boya,
Btill yo'.i will meet with the mention of boys often enough to be an-
thorized to believe that the proportion differs from that which exists
for ingrown toe-nail. I can offiir you no figures to prove this, since I
have only eight personal cases, and that ia insufficient to establish a
rule. But connecting with my results the impression left upon me
by reading published cases, 1 believe that relatively there are mora
boys aftected with sub-ungual exostosis than there are girls affected ■
with ingrown toe-nail. As to the diagnosis, however, the question
remains the same. The sex was* a circumstance favourable to the
opinion that it was an exo.«tosis rather than a cancer, and it was from
this point of view that I was led to speak to you of the influence of ,
8ex. lam absolutely unable to explain this predilection fi

I M«]gaigi.e

ixplai
« M6d!co-Chirurgici

i. p. 21 (1850).

^^12 SDRGTCAI, DISEASES OF YOUTH.

^P sex, a preililection which you will not fiml in the other dis

^f youth.

3d. As to the ulceration, the exudation, and the pains, which remio<
as of ulcerated cancer, you must remember thut the.^e incidents
quite frequent in subungual exostosis. The cause is topographical^

I it is the pressure of the shoes while walking that occasions them.
The pain is furthermore due to the sensibility, normally very great,
of the sub-unguiil dermis which is affected by the inflammation, to
the uloaration, and the lack of protection by the nail, the limits of
which are surpassed by the tumour and are generally much reduced
■ by cutting, as in this case. This cutting off of the nail is all the
easier because the nutritive trouble produced by the morbid growth
is followed by the loosening of that part which covers it.

Perhaps if the tumour had been les^ voluminous it might at firs
have been taken for a simple ingrown nail. You noticed, howevt
and this is always the ciiae in subungual exostosis, that the 'v

Ptions were not lalerii!, but placed above and in front, I admit that
the anterior edge of the nail may have contributed to their formation,
and that consequently they may have had the same origin as those of
ingrown toe-nail, but in primitive and uncomplicated ingrown toe-
nail the affection is upon the side and not on top, and it is not accom-
panied by a tumefaction which raises the front part of the nail, aud
advances beyond the anterior eilge, as is the case here.

The diagnosis havin-< bi;en made, we have to ask ourselves whether
the etiological diagnosis ought not to be completed by the indication
of soma general cuuse other than the age and aex. You often hear
us apeak of syphilitic exostoses. I have examined and questioned
this patient, and have not found, and have no reason to suspect,
syphilitic antecedents. Even had I found them, I should doubtless
not have attributed this exostosis to them, for my own experience
and that of other surgeons have taught us that sub-ungual exostosis
of the great toe, aud that of the other toes, and also those of the
fingers,' are not of syphilitic origin. The same is true for the other
exostoses of young people, and we find in this circumstance another
reason to justify the separate description of the diseases of youth upon
which you hear me so often insist,

PaLhohgical Anatomy. — Of what was this tumour composed ?
Before removing it I told you what it would probably prove to be,
but now that we have the piece in our hand.'} I can give you a more
exact account. On the surface you see the sub-ungual dermis, below
it, but intimately united with it, is a white layer, fibrous in appear-
■ ance, one-eighth of an inch thick, which seams to the naked eye
tobeforrnol of dense fibrocartilaginous tissue, but the microscope
fails to discover any cartilaginous calls in it, and shows it to bt) formed
in reality of very dense fibrous tissue. Under this, and again cou-

' Sub-ungual exintoii* may be developad npon tUa olhsr loea niiil upon tlia Bugei
All aulliora hasa poiiitail this uut. I hai'a liail ona axamplB upon tlia tliird loa, ai
ona an I'^i' Ilia □ail ul' tha inlHX Qui^ur gt' tliu rijUl I1.1111I, But it U iuSaitaly morS'

I
I

aUB-tlNaUAL EXOSTOSIS OF THE GREAT TOE. 18 '

reeled closely with it, you see a mass of bone, nearly one-quarter of
an inch thick, formed in part by the abnormal growth, and in part by
the portion of the phalanx from which it came. The tumour then
was not a pure exoatoais, it was an exostosis covered by fibrous tissue,
or, if you prefer, an osteo-fihrous growth. Jd this respect it differs
from other exostoses of youth, which are formed exclusively of bony
tissue, and it has some analogy to naso pharyngeal fibromas which
spring from the bone, but are formed exclusively of fibrous tissue.
That is to say, that in adolescents, and by the fact of the growth of
the body, perversion of nutrition leads sometimes to an excess of bony
tissue attached to the bonea themselves, sometimes to an excess of
fibrous tissue attached to the periosteum, sometimes to a simultaneous
exaggeration of both bony and fibrous tissues It is this last variety
which we have before us, and this was also the case in the other ex-
amples which I have had occasion to examine. There may be cases
in which the exostosis is purely bony, but tho.se which I have observed
have been such that T am authorized to tell you that the tumoi

merally is mixed, that is to say, osteo-fibrous.

Hh-eatment. — There is no reason to hope that these tumours can
removed by internal treatment, and I have no facts even which per-
mit me to believe that, left to itself, the disease will get well by sim-
ple increase of age. I had then to offer to our patient only an opera-
tion, and this is the one you saw me perform. First I removed the
nail after local anaesthesia by means of a mixture of ice and salt as ia
the operation of ingrown toe-nail; then I isolated the tumour by two
curved incisions, and detached it with a strong bistoury, hollowing
out a little the upper and anterior surface of the phalanx to a depth
of about one-sixth of an inch. In doing this I proposed to remove
together with the tumour all its roots of implantation, so as to protect
the patient from a return of the aftection. The bone offered but a
slight I'esistance; if it had been harder I should have used the gouge
and mallet, A simple dressing, the same as for an ingrown toe-nail,
terminated the operation.

This operation di&ers from Dupuytren's in this, that he shaved off
the base of the tumour horizontally with the blade of the bistoury,
while I used the point, forcing it in first on the inner then on the
outer aide, holding the tumour, meanwhile, with pronged forceps.
The bony substance resisted a little, but by using some force, I easily
overcame it.

You will find in the books other modes of treatment. Listen _(of
London) and Lenoir (of Paris) preferred disarticulation of the outer
phalanx, in order the more certainly to prevent a return of the trouble.
Dr. Debron, of Orleans, animated by the same desire, thought it
sufficient to amputate in the continuity of the phulanx, forming a
dorsal flap out of the sub-ungual dermis, and a plantar one. This
skilful surgeon based his operation upon two dissections which had
shown him that the origin and implantation were upon the anterior
border of the phalanx, and extended so short a distance upon its
upper surface that amputation at the point indicated might be made

14 SURGICAL DISEASES OF YOUTH.

with the certainty of removing all the disease, and preventing its
reproduction.

Gentlemen, I do not wish to exaggerate the danger of amputation
in contiguity, and still less of that in continuity, but still this danger
is certainly greater than that of the ablation to which I give the pre-
ference. The slight excavation which I made so as to pass beyond
the limits of the disease, and to the usefulness of which I called atten-
tion in 1861,^ appears to me quite sufficient to protect the patient
from a relapse. At least in none of the eight persons upon whom I
have operated in this way has the growth returned, and even if it
should return once, I feel convinced that if the patient had reached
the age of 25 or 26 years at the time of the second operation, another
return would not take place, the age which predisposes to this kind
of production having been passed.

LECTURE III.

NON-SPECIFIC EPIPHYSARY EXOSTOSIS OF YOUTH OR EXOSTOSIS OP

DEVELOPMENT.

Description of the disease — Incurability by internal treatment — Operation useless,
because the tumour is indolent and without danger, and will cease to grow after
adolescence — Surgical intervention reserved for some exceptional cases.

Gentlemen : As we finished the visit this morning we were stopped
by a young man, 19 years old, whose father came to ask my advice about
a tumour situated upon the inferior and internal portion of his son's
right knee. The tumour first appeared when the boy was 16 years
old, it has grown little by little without causing any pain, but now
that it has reached the size of a lady apple the young man and his
parents begin to worry about it, and wish to know if it cannot be
removed. You saw that the tumour was round, slightly knobbed, and
so hard that there was no doubt about its being formed of bone. The
skin that covers it is normally soft and movable. Seizing it with one
hand, and fixing the leg solidly with the other, I recognized that the
tumour was tightly adherent to and confounded with the inner tube-
rosity of the tibia.

Consequently I did not hesitate to pronounce the diagnosis exosto-
sis, and you heard me add, exostosis of adolescence. By that I wished
you to understand that there are developed in adolescents exostoses
which are not due to a specific cause, but which are purely local
lesions unaccompanied either by pains or marked functional troubles,

' Bulletin de la Soo. de Chirurgie, June 12, 1861.

BCIFIC KPIFBTSAKY KXOPTOSI3 OF YOUTH, 15i

[and which will not Jisappear under the influence of a generiil truat-
metil.
You often see in the surgical wards, and you will hereafter meet with
in practioe, patients bearing tertiary syphilitic exostoses. SometinisB
they are young people, but more often they are adults, and iu any
case the diagnosis indicates at once the existence of a general cnuse,
syphilis, under the influence of which the lesion ha^ been proiiuced,
and behind this cause the poaaibility of a disappearance under the
influence of an appropriate treatment.
On the other hand, you will often hear me call your attention
bony swellings which I call kyperoatosea. I shall tell you that thi
hyperostoses sometimes follow osteitis of infancy or of youth, but
such a case last throughout the patient's life, and become from time to
time the seat of fresh inflammatory action, and even of necrosis, I
shall further show you that these hyperostoses may form on adults,

■ especially after a fracture.
But in the case of this young man you see there has been no inter-
vention either of the syphilitic cause or of an antecedent osteitis. We
have here a very circumscribed, indolent, bony swelling, which ia due
to no appreciable cause, and which can be explained only by an aber-
rat!o[i or excess of bony development at certain points of the skele-
ton, at the time when the system 'is working to complete this latter, an
^_ aberration comparable to that which causes the formation at the same
^K age of sub-ungual exostosis and naso- pharyngeal polyps. Only, while
^H in this case the production is exclusively bony, you remember that in
^^K sub-ungual exostosis it is osteo-flbrous. and in the naso- pharyngeal
^^1 polyps exclusively fibrous,

^^1 T said that you would meet with analogous cases in your practice.
^^1 You will find them oftener upon the lower than the upper limbs, and
^^B in the neighbourhood of the extremitiea rather than upon the botly of
^^B the bone. In this connection I accept willingly the opinion uttered
^^K by M. Broca' before tlie Soci^t^ de Chirurgie upon the origin of these
^^m exostoses in the borderof the epipliysary cartilage, and more often upon
^H the side than in front or behind, and with him I give them the name of
^^M epiphysary exosto,ses. But I should like to be sure that my learned
^^1 ctilleague had had the occasion, which I, for my part, have not had, to
^^K verify the fact upon the cadaver. On some subjects you find many
^^K at a lime. In a case presented by M. Marjoiin^ to the Soci^t^ de Chi-
^^B rurgie, there were a great many of them, and they were symmetrical,'
^^B that is, they occupied the same place and had the same size on the
^V right and ou the left. It is true that this was a child six years old;
^H but although this lesion is generally seen during youth, yet like the
^H other lesions of this age it sometimes occurs in children.
^V When the father asked me repeatedly what 1 thought should be
^B done for the tumour, you heard me answer, "Nothing." The exos-
^M tosia causes no functional trouble, no pain; if there were any chance
^B that we might cause it to disappear by inojfensive external or internal

1 to^H

.e»^H
t m^^

SURGICAL DISEAaEH OF TOOTH

itreatment, we would make the attempt, for it is disagreeable for
one, and eapecially for a young man, to bear a deformity. But
know and we have warned the patient that the tumour will not dis-
appear under the influence of drugs, and that it may even increase a
little until the skeleton ia completed, that is, until the end of adolaa-
cence. Consequently I prescribed only some precautions in the hope
of preventing too great growth. I advised him to avoid long walks
and iatigue, and to cover the upper portion of the leg with cotton and
duck, BO as to protect the exostosis from external violence, or at least
totliminish its effect.

Gentlemen, observe that we could get a radical cure only by a
cutting operation. This operation, which would consist in dissecting
back the skin, uncovering the base of the tumour, and removing it
with a chain-saw or gouge, would certainly not be difficult of execu-
tion. But it would inevitably be followed by suppuration, for the
wound would he too large to permit immediate union ; the suppura-
tion would undoubtedly attack the bone itself, and the patient would
have to run the risk of an acute suppurative osteo- myelitis, the danger,
of which disease I shall often have to point out to you.

At the beginning of my studies, in 1834, I saw Professor Roux
remove by an operation of this kind an epiphysary exostosis of the
Jower portion of the femur of a stronp, handsome young man 18 years
old. Suppurative osteo-myelitis of the femur set in, and was compli-
cated by pyemia, which carried off the patient at the end of twenty,
days. Roux had performed the operation because he thought lh«-
tumour would grow until it caused intolerable pain and annoyani

To-day surgeons ought to know that — the period of adolescenc©:!
ended — tumours of this kind remain stationary, and, as a rule, causa'
no trouble in the functions of the affected part.

There are, however, exceptions. M. Broea has reported the caafl.
of a young man, 'iO years old, whose exostosis was complicated by 9
cyst developed about it. This cyst grew so large that the surgeon.',
thought an operation necessary, and removed both it and the bony'
tumour SQccesafully, I think that perhaps in such a case punctui
of the cyst, followed by an injection of the tincture of iodine, witho
touching the exostosis, might be sulficient. I should not be willi
to remove the latter unless it interfered notably with the action
the muscles.

An English surgeon, M. Coote,' was led to operate by special,
reasons which, in any case where they should present themselveg,,
would be a precise indication for surgical intervention. The patienli,
SB years old, had had for many years an exostosis of the transverse
process of the seventh cervical vertebra. The tumour, which was
only as large as a good-sized nut, projected above the clavicle, pushed
the subclavian artery forward, and forced upward and compressed the
nerves of the brachial plexus. Hence numbness and coldness of the
hand and fingers, and pain along the arm and in the shoulder. Re-
moval of the tumour, which was, of course, difficult in this region,
caused the disappearance of all these functional troubles.

t wel^l

vi Coote, 0niou MMicale, ISBl, 1

i. p. 186.

N0N-3PBCIFIC KPIPHTSARY EXOSTOSIS OF YOUTH.

In 1857, at the HSpital Coohin, I saw a still rarer exception. The

tatient, 0I years old, had had, since the age of 15 or 16, an esostosiB

fopon the inner portion of the left femur. (Figs. 1 and 2.) It had

never given him any trouble, when one day he was knocked down
by a wagon, the wheel of which, passing over his thigh, fractured
the exostosis. Its anatomical disposition was very nnusual. Instead
of a single implantation, which is habitual, it had two : the lower
one very large, the upper one smaller. It had thus the form of a
loop or of a large zygomatic arch.

The weight of the wagon caused a comminuted fracture of this
exostosis, detaching it from its insertions, and at the same time a con-
tused wound, which made the fracture compound.

Suppuration was abundant; the patient fell promptly into a dan-
gerous hectic condition; I amputated through the thigh abont the
thirtieth day, and the patient was carried off by pysemia.

With the exception then of such cases as these, fix in your minds
this fact, that epiphysary or developmental exostoses may remaii

SURGICAL DISKASB8 OF YOUTH.

without causing any inconvenience, tliat they cease to grow when
adolescence ends, and that their removn! offers dangers to which it is
absolutely conlra-iudicated to expose the patient when the tumour i
indolent and inofl'ensive.

LECTURE IV.

Hamorrliagio Kod sofTocatiiig form of Gliroma — Lnrge impUntiitiaii npon tlie li

tlis sknll — SigniGcallon of the irord pnlj'p — PalllaiUve operBtions — Nfilaton'a
operatiou — CauUrizalioD by elsotrolyaia — Mitria aoid — Chloride of zino — Increaae
' — £xophlbalmia, huiuiplegia, their di«app«a ranee at the age of 26 years.

Gentlemen: We have just seen, aa we completed the visit, a
young man, 23 years old, whom I have treated in our wards for
nearly two years for a naso-pharyngeal fibrous polyp which had be-
come sufFocating and hemorrhagic, and who appears now to be cured
of this serious affection. His history is so instructive from all points
of view, and especially with reference to the influence of age, that I
wish to relate it to you again, and beg you to engrave it upon your
rainde.

This young man, Joseph Pellard, entered our wards for the first
time the 21at of April, 1869. He was then 22 years old. He told
U8 that since the age of 16 or 17 he had noticed a change iu his voice,
which had grown nasal, and a slight difficulty in breathing through
his nose. During several years these functional symptoms troubled
him so little that he paid no attention to them and consulted no one.

At about the age of 20 he bled frequently from the nose; but
although the nasal tone had increased, and respiration through the
nostrils was impossible, he was still able to live without treatment.
After some time the epistaxea became more frequent, though not very
abundant; each time the respiration became more embarrassed, and
deglutition was difficult. The patient was then obliged to consult a
physician, who sent him to me for the surgical treatment which he
considered necessary.

The day we examined the patient for the first time, we found that
he was large, well formed, and did not have the pale look of anfemic
subjects, which proved that the quantity of blood lost had not been
considerable. What struck ua most was the frequency of hia respira-
tiona, and the snoring sound which accompanied them. Questioned
upon this point, the patient said he did not generally feel choked, but
he was short of breath when walking, and for that reason could

I'HARTNOEAL FIBROMA OR FIBROUS POLYP.

I neither walk fast nor run, He added that on two occaaions, withoat,'
apparent cause, ha had had short attacks of sufEbcation. His face
was not deformed.
In order to examine the nostrils and nasal fossce, I placed the
patient before a window, introduced succes-si uely into each nostril
Duplay's bivalve naaai speculum, and saw, at about three-quarters of
Wi inch from the nostril, on each side, a round reddish body. I told
the patient to close the mouth and make a forcible expiration, and
thus discovered not only that these round bodies were [iot pushed
forward, but also that not a particle of air escaped through the nasal
foss», and that consequently these latter were entirely obstructed.
At the same time, I mentioned that the intra-aasal tumours had
neither the flattened form nor the pinkish-gray colour of mucous
Carrying, then, my investigation into the pharynx, I saw at once
that the soft palate was pressed forward. I tried to press it back
with my finger but wa.s unable to do so, finding resistance upon the
sides as well as in the median line. Then depressing the tongue, I
saw in the middie of the pharynx a round reddish body extending
nearly half an inch below the edge of the palate, and evidently con-
i with the resisting body above it. finally, passing the right
►index finger beyond the palate, I felt that this fleshy body occupied
R^Il the upper or nasal portion of the pharynx, I could pass the end
f my finger between it and the wuU on the right side, but not on the
left, but it was impossible to get behind, or above, or to move it,
■because it occupied the whole space, and seemed to be fixed upon the
f£rst cervical vertebra.

By these physical and functional symptoms, I recognized one of
■hose tumours so well studied recently by Professor N(5iaton, which
Bwe know by the name of naso- pharyngeal polyps.

as not a mucous polyp, because, in the first place, polyps of
ihat kind do not ordinarily reach sTich a size, secondly, because it wan
tdder, and above all, because its conaiateacy was firmer. All these
' points are characteristic of fibrous polyps.

The size of the tumour might have given rise to the idea of its
being a cancer, and its resistance to the remedies employed during
eighteen months might afterwards have confirmed this idea. But

•there was no ulceration ; now, cancer of the nasal, buccal, and pharyu-
geal cavities, hardly reaches this size, and does not last so long with-
out ulcerating. On the other hand, cancer, especially canuer that
progresses slowly (this tumour was at least five years old), is very
rare at this age.

Finally, M. N^laton's researches have taught us two things which
ought to be utilized in the diagnosis. The first is thut naso-pharyn-
L ^eal fibrous growths are seen especially upon young people, and th»
l.^oond is that they are seen almost exclusively upon boys and nof
I upon girls.

The cases which I have met are entirely confirmative of these two
KippinioDs. I have seen naso- pharyngeal fibromas only upon adolt

face ^H

I
I

'20 aURGICAL DISEASEa OF TOtTTH

cents and upon boys. I have read of aomc cases where the patients
were girls; but I am not sure that, the diagnosis was correut.

Apropos of that, gentlemen, let me put you on your guard against
the titles given to many facta in books and periodicals published
before 1848. Up to thai time they had not had occasion to make the
distinctions among naso- pharyngeal tumours which we make to-day,
and they gave the name of polyp to every growth which projected
into the naso pharyngeal cavities, without occupying themselves with
the nature of the tissue of which the tumour was composed. We now
know that there are found in these regions, fibromas, epithelionaas,
and cancers, which resemble one another by many of their physical
and functional characters. Now, wViile the two latter may appear at
any age and in both sexes, the first present the two etiological pecu-
liarities which I have just mentioned.

I will not go so far as to affirm that naso- pharyngeal fibrous polyps
never appear in girls. I only say that neither M. N^laton nor I have
yet observed a positive example of it.

The age and sex, then, of our patient, favoured the opinion that
the tumour was a fibroma; but I used the expression polyp. What
do we mean by this word, and is it rightly used here ?

Clinioally, we have long called polyps tumours developed and free
in those natural cavities of the botiy which communicate with the
exterior, and most of which are covered by a mucous membrane,
tumours of which one of the principal characteristics is that they are
attached by a pedicle, that is to say, by a portion which is smaller
than the free and prominent portion of the tumour. This word
"polyp" has the disadvantage of conveying no a nato mo- pathological
idea. Modern surgery, however, has retained it for two reasons:
first, because the presence of the pedicle indicated by this word leads
to operations relatively easy (ligature, excision) and different from
those necessitated by the tumours of other regions; second, because
the pedicle carries with it the idea'of non-malignancy, that is, of not
being cancerous. I canuot tell you why it is so, but such is the fact,
and I formulate it thus: In the natural cavities cancerous tumours
are not pedicular ; only non-malignant tumours have a pedicle.

That, however, does not mean that non-malignant tumours always
have a pedicle, and in fact, in the case of a young man of whom I
am now speaking, I was authorized, for the reasons I have given
you, to admit a fibroma; but I was by no means authorized the first
day, and you will see I have been less and less so ever since, to
admit a pedicle. I could not see one, and with my finger I could
feel only a small portion of the tumour free, while the latter was
absolutely immovable, and I thought I found a sort of fusion
between it and the corresponding portions of the skeleton, the ba-
silar surface of the occipital aud sphenoid, and the lower face of the
petrous portion of the temporal. If, then, the tumour was pedicellated,
it was impossible for me to determine it at first, and I was obliged to
reserve that part of the diagnosis until, the tumour having beea
dimiaished in some way, I should be able to carry my finger around
it and see if the implantation was notably smaller than the free

NA30-PHABTNGEAL FIBROMA OR FIBROUS POLYP.

■portion. I will tell you now that my later explorations demonstrate
the absence of a pedicle and the existence of a large base of i
plantation. Consequently it was not a polyp, in the rigorous accepil
tation of the word.

If you have heard me still use the expression, it has been beoauat
on the one hand, it had this other signification, that in my opinic
the growth waa fibrous and consequently non-malignant, and, on the
other band, I waa justified by usage. In the works which have been
published in France upon thia subject under the inspiration of N^laton,
especially in the theses of Drs. Perier and D'Ornellas, as well as in I
the discussions upon the subject, the word polyp has been habituallyj
used to indicate every kind of n as o- pharyngeal fibrous growth olT
adolescence.

Remember, nevertheless, to make this distinction, that among th<
tumours of this kind, some are distinctly pediculated, others ai
pletely sessile, and I will show you hereafter the importance of thid
distinction for the treatment.

The anatomical diagnosis being thus established, naso-pharyngea
fibroma broadly implanted upon the upper wall of the pharynx, andfl
projecting at the same time into the two nasal fossse and into the io'
ferior and middle regions of the pharynx, I completed it, by adding
that the tumour interfered enough with respiration by blocking up
the air passages to deserve the name of suffocating fibroma or polyp.

In this last quality Say the necessity for surgical intervention. J
But what was to be done ?

I passed in review all the simple and compound operations whioM
have been recommended for cases of this kind. I saw at once thadi^
aimple operation was impossible on account of the size of the tumnan
and that it was necessary to select one of the complex and mnltiptf
ones which I was the first to distinguish as preliminary^ fundamer,
, bnd complementary}

The end proposed in these operations has been to separate th(
tumour completely at the point of implantation, in the hope of there
by removing it entirely and protecting the patient from ; ' _
which, according to the experience of N^laton, confirmed afterwards
by that of all surgeons, is very common in this disease, and has been
attributed to the insufficiency of the removal. The reasoning, ap-
parently correct, waa this: Let the surgical intervention be such aa
will entirely remove or destroy all the roots of the tumour, and its
reproduction will not take place. Some facts agreed with the theory,
but others, and they were quite numerous, disagreed. Reproductions
occurred in spite of all the care which had been taken to shave off
the surface of implantation, to scrape it and to destroy all that could
be considered as forming part of the tumour. To be convinced of
this you have only to read the tables prepared by M. Michaux i*
in 18B7.' He has collected twenty-seven cases of total i

' Qoselili, TrBitflment chimrglaHl des Polypes des fossel iiaaales at du pharynx.
Tbtau da Coocoura pour ane Cliaire do USdudus apSrstaire Paris, 1S50.

' MiohBiUx (de Lonvaiii) Qaelqiioa Mota encore Burles Polypes Qlireni naao-phuryu-
giaos Tolamiueui:. Balleliu du I'AcudBmia do Belgiqae, 3d sfirie, loma i. in 4io.

SURGICAL DISEASES OF YOUTH.

eeutioQ of the superior maxilla wbich resulted in eighteen complete
successes, one incomplete, two relapses, and tliree deaths; and twenty-
nine oases of removal with resection of the palatal arch, which gave
twelve successes, five incomplete results, three unknown, four rehpses,
and five deaths. I am not at all sure that the successes given as
complete remained such indefinitely; some of the patients may have
had relapses after the surgeon had lost sight of them. But it is
nevertheless true, according to the known results, that a relapse is
possible after serious prelimioary operations which permit the entire
removal of the tumour.

I had then to determine whether, in order to save my patient from
the death by suffocation which threatened him, I ought to perform
a serious preliminary operation which would give me free access to
the surface of implantation, so that I might attack the latter with cut-
ting instruments, and afterwards, if neccessary, cauterize it. I had
to choose between iocisioo of the soft, followed by resection of the
hard palate (N^laton's method), and resection of the superior maxil-
lary bone, as practised by Flaubert of Rouen, Robert, and Michaux.

I was but little tempted by the first, because, the surface of im-
plantation being probably very large, I should have been unable to
get an opening large enough to allow me to operate upon it properly.
This preliminary operation, which has the great advantage of sparing
the face and leaving the alveolar-dental arch intact, appears to me
to be sufficient and preferable when the implantation is small, when
it is limited, for example, to the basilar surface of the occipital bone;
but it is certainly insufficient when the implantation is very large, as
was the case here. With reference to the certainty of execution,
the maxillary route was undoubtedly preferable. But besides the
inevitable disfigurement which it causes, it is more serious and is
more likely than the former to lead lo purulent infection. I know
that the statistics published by M. Michaux seem to prove the
contrary, but remember, and this objection applies to all statistics
based on observations gathered from journals, that all the cases, and
especially the unfortunate ones, have not been published, and that
consequently statistics of this kind, in spite of their apparent exacti-
tude, do not definitely settle the question of the comparative danger
of different operations. For my part, I am convinced by the results
of resection of the upper maxilla for other affections than polyps, that
this operation is more dangerous than resection of the palate. More-
over, in the present case it was not only the preliminary operation,
but also the fundamental one, which was dangerous. This great
tumour was very vascular, for it had frequently occasioned epistaxis,
and there was reason to fear that if I attacked it with the bistoury,
scissors, or hooks, the patient would die upon the table from hemor-
rhage.

fiefiecting upon those dangers to which a complicated operation
exposed the patient, I thought of the influence of age, and asked
myself whether the patient, being twenty-two years old, was not near
that period of life in which tumours of this kind have no tendency
to be produced, and consequently none to reappear. I remembered

NAaO-PHARTNGKAL FIBROMA OR FIBROUS POLYP.

rlliat my learned friend and colleague, M. Legouest, had uttered
formally, before the Sociijt^ de Ohirurgia in 18ti5, the opinion that
naao- pharyngeal polyps might be treated by a simple and palliative
operation until the period of their habitual formation had passed.

Furthermore, having, as I have just told yon, no very precise
notions as to the extent of the implantation, and not being willing

I to engage in a perilous operation without being better informed, I
decided to confine myself at first to a palliative operation whinh
should have a double object, that of relieving the patient from the
danger of suffocation, and giving me more definite ideas as to the
connections of the tumour by which my future action would be de-
termined.
Having decided upon this plan, I proposed soon to put it into
operation, when, on reaching the hospital on the morning of the
27th of April, I learned that the patient had had during the night a
violent fit of suffocation which had nearly proved fatal. There waa
then no more time to be lost, and I performed the eame day a palj
liative operation intended to prevent asphyxia. ^

The patient having been seated upon a chair in front of a windotfJB
I divided, as an indispensable preliminary operation, the soft palate'
along the median line, and resected a portion of the hard palate
(N^laton'a method), and by the way thus opened I introduced a strong

■ pair of polypus forceps, with which I seized the tumour and tried to
draw it towards me, combining the movement of traction with that
of rotation. After using considerable force I brought away a very
small piece of the tumour; I tried again two or three times, without
soy success, and then taking a pair of pronged forceps I fixed them
firmly in the morbid mass and cut beyond them with strong carved
scissors; this time I brought away a piece as large as a walnut. I
then repeated the manoeuvre after giving the patient time to rest
I »nd spit.

The operation bad not been very long, but the young man htK
ost considerable blood and felt weak, so I decided not to try lo rfl
fcjQove any more, and occupied myself with checking the flow of blood.
For that purpose I touched the bleeding portions of the tumour
several times with a brush dipped in a mixture of one part of per-
■■ehloride of iron at 30° and three parts of water, and made the
patient gargle his thi'oat with a still weaker solution of the same
preparation. The flow soon stopped, and the patient waa able to walk
back to his bed. The following days respiration was much freer,
raftbcation no longer threatened, and no accident consecutive to the
deration endangered the life of the patient. In a word, my incom-
plete and palliative operaiioji had had none of the unfortunate con-
quences which might have attended an attempt at a radical cure,
piill we were far from a cure, and had even to expect an i:
'itie portion which had not been removed.

I I should mention that the portion removed waa examined, an^
bund to consist of a fibrous framework and a rather large numb«|
f bioodvesscls.
Esftmining the patient daily, I discovered between the twetitlet

.24

V S4

^M and tliirtieth days that tbe tumonr irjcreased a little above the soft

^F palate; without waiting for it to become sufficiently large to again

interfere with respiration, T Buhjected the patient during the next

two months to ten operations with the electrolytic apparatus. You

remember that the arrangement of the currents in this apparatus ia

I such that they produce a sort of cliemical destruction and elimination
of the tissues traversed by them, which, however, is not a real gan-
grene.
Thoae of you who assisted at those operations remember that they
lasted ten or fifteen minutes and were quite painful, also that the
eschars produced were small, and that the tumour increased again as
soon as the elimination was finished. In short, after two months
nothing had been gained or lost; the fibroma was no longer suftb-
cating, and in no way did it compromise life, but it was still there,
and I easily recognized every day, by passing my finger through the
division of the soft palate, that the tumour was sessile and occupied

*a large surface, that it did not belong to the category of polyps,
properly so called.
After two or three more weeks passed in observation I recognized
that the tumour continued to increase, without, however, becoming
large enough to again cause theauftboation which had so incommoded
and threatened the patient at the time of his admission into the
hospital. Furthermore, there was no flow of blood except on the days

I when the tumour was touched either for exploration or for electrize
tion, and the general health remained good. *■

Anxious to keep the disease in this condition, that is, within i^^
limits compatible with health, continuing to fear the consequences
of a great curative operation, and hoping that one day or another
the influence of age would make itself felt, I gave up electrolysis,
which caused a good deal of pain and yielded only insufficient
results, and I decided that thereafter the tumour should be attacked
and destroyed as far as possible by means of caustics applied through
the opening in the palate or through the nostrils. At first I used
monohydrated nitric acid, carried through the division of the palate
with all the precautions necessary to prevent its falling into the
pharynx and oesophagus. This mode of cauterization had the ad-
vantage of causing but little pain and no loss of blood; but it had
the disadvantage of destroying only the surface and not at all the
parenchyma. For this reason I ultimately had recourse to the ap-
plication of points and grains of chloride of zinc, giving to the
» caustic, which was well dried and composed of one-third chloride of
zinc and two-thirds flour, the form and dimensions suitable to the
passage through which I had to apply it. Three different times I
attacked ihe nasal prolongations which had grown nearly down to
the nostrils, and for that I used grains having the form and size of
oats. For the pharyngeal portion, on the other hand, I used tri-
angular points having a length of from one-half to three-quarters of
an inch, and a breadth at the base of one-third of an inch. These
points were applied by means of long polypus forceps, and I was
careful to choose those whose points were the hardest. Notwith-

INi.50-PHARTNQEAL FIBROUA OK FIBROUS POLTP. 2S^H
Standing the bardness of the tumour, T never had to make a pre1imi<^^H
nary incision with the point of the bistoury. I applied every timtf^^|

two or three of these points. The operation had the dicadvantage
of eansiog the biood to flow for from fifteen to thirty minutes. But
as tbe patient ate well, and repaired rapidly, and as in fact the amount
of blood lost each time was hardly more than three ounces, the dis-
advantage was not too great. I noticed only that the tumour became
more and more vascular as it grew older.

Such was the condition of affairs during August and September;
caustics had been applied ten different times, and had produced eschars
of greater or leas size. In short, the tumour was smaller than at
first, but there was still the same extent of implantation and the
same tendency to increase as soon as we ceased to employ the means
of partial destruction, Wearied with his long Stay in the hospital,
and not considering himself ill enough to remain, the young man
begged to be allowed to depart, promising to return if he did not
get better.

He left us on the 18th of October, 1869, baving obtained from
his five months of treatment this important result, that oar first pal-
liative operations had saved his life, but with the chagrin of knowing
that he was not cured, a chagrin that he felt very keenly, notwith-
Utanding the hope we gave him of a cure at the end of adolescence.

When he returned two months later, the SOth of December, 1869,
Pellard informed us that he had had no fresh hemorrhages, and that
his health continued gnod, but that for some time he had felt that his
respiration was again becoming afl'ected. Furthermore, although he
felt well, he had grown thin, and I pointed out to you a beginning
of exophthalmia on the loft side; I attributed it to this, that the left
fiasal prolongation had destroyed the outer wall of the nasal fossa and
extended into the orbit. I again attacked the tumour twice with caus-
tiii points, which caused free bleeding each time. 1 was still unwilling
to resect the superior maxilla on account of the dangers I foresaw
both from the operation itself and from the necessity of severing such
extensive connections of a very vascular tumour.

Meanwhile, on making my visit one morning in February, 1870, the
patient told me that, without having lost consciousncBS, lie had felt
when he awoke that morning numbness in his right arm and leg, and
fre discovered then and on the following days that the upper and
lower limbs on the right side were partially, but evidently paralyzed;
and ns the exophthalmia continued and even increased, I was forced
to think that the cribriform plate at the upper wall of the left nasal
fossa had been affected similarly to the outer wall, that is, had under-
gone a destruction and perforation which permitted the tumour to
extend towards the cavity of the skull and compress the brain.

However that may be, I at once abandoned all hope, and thought
the young man would be soon carried off by meningitis or some
other cerebral affection. I regretted that I had not removed and
cauterized the tumour at the beginning, after preliminary resection
of the superior maxilla, for I now considered such an operation im-
IKMaible, siDce there was reason to fear that the removal of the uijijie.^

r 26 BURQIOAL DISEASES OF TODTH,

I
I

portion of tbe tumour would open a large communication betwi
the nasal fossa and the cavity of tbe cranium ; I therefore alJowed
patient to quit the hospital again the 27th of March, 1870.

What was my astonishment toaee him return the 16th February,
1871. I had heard nothing of him for a year, and supposed him to
be dead. On the contrary, be came to tell me that since his depart-
ure his health had steadily improved in spite of his participation in
the fatigues and privations of the siege of Paris, The weakness of
the right side had disappeared little by little; no cerebral symptom
had occurred; the prominence of tbe eye existed no longer, and yet
new treatment had been undertaken. The only incident was
that in September, 1870, more than five months after he bad left La
Charity, an abundant epistasis occurred and obliged him to enter the
Hotel Dieu, in the wards of M. Lsiugier, who undertook no surgioi
treatment, liut contented himself with prescribing some ^

By making him breathe through bis nostrils, I ascertained that th(
air passed freely. Examining him in a good light, I no longer
in the nasal fossa the round red bodies which were formerly there.
Opening his mouth, I saw the median division of the soft palate
which I had made, bat no tumour above it; I could pass my finger
above the palate throughout the wliole upper portion of the pharynx
exactly as in those who have no polyp. The only thing of which
the patient complained was the nasal tone of his voice resulting from
the defective condition of the palate, I proposed ataphylorraphy Kt
once, to which he did not agree, but he promised to return later an^ I
have it performed. • i

To recapitulate, gentlemen, we have a young man twenty-two
years old, who has juat escaped being killed by a suffocating naso-
pharyngeal fibroma. A palliative treatment prevented death, and
afterward kept the tumour from again becoming suftbcaling. At the
age of twenty-four and a half years, and without any further surgical
treatment, the rest of the tumour disappears spontaneously, being
absorbed, not eliminated. Repair of the orbital and naao-oranial
walls takes place by means which we do not exactly understand. The
symptoms of compression of the eye and brain disappear, and, in
abort, the patient appears to be cured.'

This fact is certainly favourable to the opinion of M. Legouest, but
we must ask ourselves if, perchance, it is not exceptional. I have
looiced for the records of similar cases, but have found none,

M, Legouest said that in tbe case of the young man eighteen years
old, upon whom he operated in 1865, be intended to make only a
palliative operation by tearing out the tumour through a nasal open-
ing previously established by making an incision in the genio-nasal
fold, dividing the naso-maxillary suture with a Liston's forceps, turn-
ing outwards the inner wall of the maxillary sinus, and leaving this

1 Since tliia article was put in t^pe, this patient has wHtteu to me [hat be in again
Buffering, and lias from tima to tiiiiH freali humorrliages from tlia [lose. He is far
from Paris, and I have not beau abla to see liiin. If it is a. relnpae, the details I
have giren noold none the less jiistifjr my opiiiiona upon tlie iiitluenGe of age, and
aathorize me to balieTe tliat a new IreatmeTit, now tliat the patient id tveul^-five
^ejirj Bid, weald ;ield a dutluitivu »aucess.

rNASO-PHARYNGBAL FIBROMA OR FIBROUS POLYP. 27
sbnorma! route open so that he might again attack the polyp after the
reproduction which he expected, ami which indeed took plaoe a few
moniha later. But this time the tumour was attacked by ganaretioua
inflammation and fell. M. Legouest did not know if the polyp had
grown a third time, or if a complementary operation had been per-
formed to close the artificial nasal opening. But if, thu3 far, surgeons
have not been guided, like M. Legouest and myself, in their thera-
peutical decisions, by the thought of the influence of age, some facta
favourable to our opinion have appeared. Thus, in the discussion

i which took place in the Soui^t^ de Chirurgie in IStifi upon this subject,
Velpeau reported two cases in which the patients, operated upon by
the simple method of extraction, one twenty years, the other nine
years before, had remained perfectly well though retaining upon the
basilar process an abnormal prominence which grew no larger. Vol-,
peau indicated the analogy between the behaviour of naao-pharyngeal
polyps and that of uterine fibromaa at the period of the menopauae.'
We know that often after the cessation of tlie courses these fibromas
or myomaa diminish, and even disappear. It may well be the same
for the fibromaa of the basilar process. On the other hand, it must
be admitted that after a certain age naao' pharyngeal fibrous polyps
are no longer produced, since to ray knowledge no observation haB.i
been published of an adult having a polyp of this kiad after it had
been operated upon during youth. All the published relapses otj-
ourred in young people. After the age of twenty-five years we hear
nothing of them. The rea.son is that those upon whom the operation
Bucceeded were permanently cured, or that those in whoin a repro-
duction took place got well spontaneously, like my patient, without
undergoing another operation.

Further observation will decide the question, but for the momentjj
I fee! justified in repeating to you what I said not long ago about in-
grown toe-nail: do not worry too much about relapses; this is a
diseaae of youth ; help your patient to become an adult, and, if his
tumour does not disappear spontaneously, the chances are great that

»you will then be able to cure him by a simple operation without re-
lapse.
►■ We must now seek to answer the question which you hear me aski.
ibr all the diseasea of youth. What is the cause, and how explaia i
the influence of this age upon the development of uaso-pharyngeal-
fibromas? ,

I shall not spend any time upon this point, because it is impossibl^.^
for me to give the problem a satisfactory solution. I might indeed
tell you that these tumours have their origin in the submucous tissue
which is at the same time tlie peritoneum of the bones of the baa»
of the skull which limit the pharynx above, and that at the period
when the development of the skeleton ends, an aberration and an .;
exuberance of nutrition may take place in this periosteal envelope.
But I know how hypothetical this explanation is, and prefer to spend ]
H^ Qo time upon it, but to confine myself to the indication of the fact^^
^B as to which there is not the slightest doubt. 4

^^L I shall be less troubled to draw from what has preceded thiaj

4
4

I "

SURGICAL D1SEA8S8 OF YOUTH.

I
I
I

therapentioal conclasion, that preliminary operations, intended to gi'
free access to the implantation of these tumours, should be perform!
only exceptionally. An explanation of this ia necessary, for thw
plan adopted should necessarily vary according to the age of t!
patient, the size of the tumour, and, above all, the extent of implani
tion.

1. Suppose first that the patient is still far from the age at which
presumably, adolescence being ended, there will be no more tendency
to the reproduction of the fibroma; suppose that he is from thirteen
to eighteen years old, and suppose at the same time that the tumour
is not very large, not larger, for example, than half an egg, and that
examinations with the finger and eye have shown that a pedicle
exists and is not very large, that the prolongations into the nasal
fosBffi do not obstruct these cavitea entirely, and that there are no ap^,
preciable ones on the; side of the ptery go- maxillary fossa or of thfj
orbit.

In such a case the surgeon ought to be guided by this thought,
that the disease left to itself will Increase, and ultimately send out one
or another of those prolongations which destroy the bones of the
face, and become hemorrhagic, if not so already, and even suffocating.
He should therefore consider intervention necessary. But in my
opinion, he ought to reject every preliminary operation, and have
recourse to one of the ainaple ones, especially extraction or ligation;
and, as extraction through the nostrils is almost impossible, he should
attempt it through the mouth, making use of good curved forceps
and helping it with a finger. This attempt is rational for two reasons :
first, because the pedicle of a Gbrous polyp may be small enough to
allow of its being torn off; and, second, because certain single naso-
pharyngeal mucous polyps may, like the example I published,' de-
velop in young people, the diagnosis between them and fibrous
polyps is almost impossible before removal, and they are very easily
torn out.

If the attempt to tear out has failed, recourse must be had to the
ligature. Passing through one of the nostrils, the patient being seated
before a window, a Bolloc sound, the spring of which is projected
into the mouth, and fastening to the end of this spring the two ends
of a very strong thread of triple silk, or of thai kind known as
twisted silk; the two ends are brought through the nose by with-
drawing the sound, and the loop is carried behind the polyp. This
is the dificult part of the operation ; if the tumour is not very large
it may be done with the fingers; but do not forget that, to render it
easier for the patient, il is well to prescribe fifty or sixty grains of
the bromide of potassium daily during the four or five preceding
days. You know that in many people this drug causes a notable
diminution of the sensibility of the palate and pharynx.

If the fingers are not sufBcient it will be necessary to use a porte-
ligature. The one which I prefer is that of Felix Hatin. (Fig. 3.)
But if you do not possess one, or if you do not succeed with it, you

I GosBBlin, Ssaatte des Hflpiiaui, IB6G, p. 45^.

NA30-PHARTNQBAL FIBROMA OH FIBROUS POLYP.

till aeize the polyp on each aide with pronged curved forceps, and
they are buld in place by an assistant slide the loop along theru.

may still seize the
while

I
f

After the loop haa been put in place, it is well to transfix the tumour
above the soft palate with a curved needle carrying a long thread by
which the polyp is drawn forward and kept from being swallowed
when detached.

The operation is completed by paaainjf the two ends through a
Graefe's ligator and gradually tightening the loop.

Here we have to choose between slow section requiring several
days, and extemporaneous section in an hour or two. I should now
give the preference to the latter, and I should make the intervals
between the successive tightenings longer or shorter as the bleeding
was more or less abundant; if it was enough to make me expect
hemorrhage after the section wiis completed. I should increase the
constriction only once or twice each day — that is, I should malie slow,
instead of extemporaneous ligature.

Gentlemen, in having recourse to extraction or to ligation withont
preliminary operation, you offer, it is true, only a palliative remedy.
But you give your patient two advantages: you do nothing to en-
danger his life, you do not mutilate bis face or his mouth. Do not
forget that division of the soft, and resection of the hard palale,
exposes your youthful patient to the chance of having for the rest of
hia life a nasal lone, and all the discomforts of a permanent communi-
cation between the cavities of the mouth and nose. Do not think
that you will always be able to remedy this by staphylorraphy, aided,
if necessary, by staphyloplasty, for these operations do not always
succeed ; often they succeed only imperfectly and leave an opening
more or less small, the discomforts of which are about as great as
those of a large one, and can be remedied only by an obturator. And
think for a moment of the diacomforta of always wearing an obtu-
rator I

00 the other hand, resection of the superior maxilla condemns the
patient, if he survives, to the deformity of the face, which results
from the scars and the loss of teeth. Modern prothesis has made
great progress, I know; but, like the obturator, would not artificial
teeth be a grievous burden for the long years that follow adolescence ?

1 much prefer the palliative operations of which I have spoken.
There may be a relapse. Very well ! Begin again as often as

may be neceaaary, only advise the patient not to delay too long, not
to let the fibroma grow too large. Repeat, as often as may be neces-
sary, those operations which compromise neither the Hfe nor the ap-
pearance of the face and mouth, and when your patient reaches the
age of twenty-three, twenty-four, or twenty-five years, perhaps even

^m SO 8UBOICAL DISEASES OF YOUTH.

^M more, reproduction will ceaae, and you will have rendered him tha><
^K great service of saving his life without mutilation.
^K 2. But we must now suppose another case, which unfortiinatel;
^H will still present itself too often. The subject, as before, is betwee]
^H thirteen and eighteen years of age; the fibroma has become very,
^^ large, it sends out many branches, or is suffocating, or is hemor'
rbagic. Tearing it away can give only imperfect results, and those
of short duration ; ligation is rendered impossible both by the com-
plete obstruction of the nostrils and the extent of the implantation.
il should certainly make one or two atttemps to tear it away, but if
they did not succeed we should have no right to hope that, under
the supposed unfortunate conditions, life could be preserved until the
end of adolescence.
It would then be proper to perform one of the combined operations
which we long supposed to be radical, and to give the preference lo
resection of the superior maxilla as the prelimiuary operation.
If, as is always to be feared, reproduction should lake place, it
might be combated successfully until the end of adolescence by
partial extractions and cauterizations, as in the case of my patient,
practising if necessary a new preliminary operation, division of the
Boft palate.

You see that here the ideas which we have as to the influence
youth lead us to not despair, and to continue to struggle against the
chances of death. But the contest is no longer possible without
mutilation; we must accept it, since we can do no better. The
important thing is not to inflict these mutilations upon the patients

I when they can be avoided, and they can be avoided if we remember
that simple operations, at first palliative, may by the influence of ags^
become curative.
3. I have now a last supposition to make. The subject is more
than eighteen years old, and is nearer the end of adolescence. His
constitution is more vigorous, and he is better able to resist the injuries
which the polyp may occasion. Moreover he has not to remain ex-
posed so many years to this injurious influence. In this ease we
ehould again content ouselves with simple operations, or with pallia-
tive cauterization after incision of the soft palate, to which we might
add resection of the hard palate as advised by N^laton. Kesection
of the maxilla appears to me to be still more exceptionally indicate^
at this age, and should only be performed if the surgeon, after having^l
long studied his patient, has become convinced that palliative opera*
tions will not suffice to keep him alive until the end of adolescence; ■
and if, after the patient has passed this age, when for example he is-
more than twenty-six years old, the tumour does not diminish by ab-
sorption or by spontaneous gangrene.

tl do not possess enough facts to be able to tell you what propor-
tion of fibromas disappear spontaneously after the subject has become
adult. I certainly believe there will always be found patients in
whom this disappearance will not take place without surgical aid,
this intervention in inevitable it is important that it should be delerred
until that period of life in which we are almost sure its reproduciioQ
^^ irj]} not take place.

NON-B0PPDEATING KPIPHTSARY OSTSITIS.

LECTURE V.

TWO CASES OP StTBACUTE HON-SUPPURATrNO EPIPHYSAKY OSTEITIS.

I. Fall npon tha knee — Fonuation of a painful awfllling over the anterior I
the tibia — Abaenoe of fe^er — Reasons for tbinfcing that the o^itHitifl i
purate, and will terminate in a alight hypertrophy after a simple
n. Fall npon thepreal trochanter — Analogous symplomg — Non-snppnrating and
hypertrophic osteitis of youth.

Gentlemen: We have at present, in the wards, two young men
, affected by the same dLsiease in different regions. One of them is
cured and will soon leave us, the other entered two days ago, and J
wil! doubtless remain for some time with us, IB

I. The first is seventeen years old and well formed. He told tnf*
■when he entered the hospital a fortnight ago, that he had fallen upon
the right knee while running, and that since that time he had not
ceased to feel a pain which was at first alight enough to allow him
to walk and work as usual, but which increased little by little, and
was accompanied by a swelling sufficient to oblige him to stop.

You remember that when we saw him for the first time he was
without fever, and had at the anterior superior portion of the right
tibia, immediately over the anterior tuberosity of this bone, and evi-
dently conlinoouB with it, a hard rounded prominence, slightly painful
when he walked, and very painful when even moderate pressure was
made upon it with one or two fingers. There was no redness of the
skin, no subcutaneous thickening. The temperature of the region
seemed a little higher than that of the opposite side. It was evident
from its situation that the trouble occupied the anterior tuberosity of
the tibia, and that this tuberosity was one-quarter, perhaps one-third,
I larger than that of the opposite side. Being carefully questioned
1 upon this point, the patient assured us explicitly that his two knees
were exactly alike before this last accident, and that the difference in
size between the two anterior tuberosities had existed for only a
week.

I examined the articulation and found in it neither effusion nor
thickening of the synovial, and, as none of the symptoms indicated a
phlegmon, and as the age of the patient, the recent appearance of the
tumour, and its limited extent dismissed the idea of its being an osteo-
sarcoma, 1 admitted the existence of an osteitis developed almost
exclusively upon the anterior tuberosity of the tibia.

As the pain was moderate, and as the inflammation was not propa-
gated to the connective tissue around the bone, and as there was no
fever, I did not mean by this one of those acute suppurating osteites
which sometimes appear upon the extremities of the long bones while
they are still epiphysary, that is, not united.

SDBQICAL DI8BABKS OF YOUTH.

H«2

^H Neither c!id I say that this was an epiphysary exostosis of youth,,

^^rlts rounded form and hardness certainly recalled exostosis, but its,

situation dismissed that idea, for exostosis is a bony growth entire!^]

new and generally indolent. This was indeed a bony prominence, batj

it was not of new formation ; it was simply a normal apophysis.

I slightly increased in size.
Dismissing then acute osteitis, osteo- sarcoma, and exostosis, I ha0
to admit a ^ow plastic osteitis, one that was subacute rather thai
'chronic.
Seeking next the etiological diagnosis, I found none of the general
causes which contribute to the development of diseases of the bones.
No anterior or hereditary syphilis, no scrofula, no sign of rheumatism.
I could find then no other cause than the contusion mentioned by the
patient, and as this contusion had been slight, and as, furthermore, I
had several times seen a similar swelling develop at the same point
upon young people without the intervention of any traumatic cause,

II concluded that behind this occasional cause there existed a predis-
posing one, the age of the patient, and his aptitude to take on, in the
neighbourhood of the epiphyses at the time when the nutrition of the
bones was working actively to complete ossification, an exaggeration
of this movement which thus became an osteitis.
In speaking to you about the prognosis, when the patient was ad*
mitted, I said that what preoccupied me most in osteitis was the
possibility of its going on to suppuration, and then to purulent infeo-
tion or caries and necrosis. But I added that in the present case we
had but little reason to fear these terminations. I did not expect
putrid osteo- myelitis, because the inflammation was not an acute febrile
one, and because subacute osteites are rarely followed by these putrid)'
changes which are the sources of poisoning, and of which I shall often
^^ have occasion to speak to you.

^K Nor did I much fear a chronic suppuration which might leave
^^B behind it caries or necrosis, or both ; for the patient was not lymphatic,
^H and his constitution was not of the kind which predisposes to suppu-
^H ration of the bones. Furthermore, I had seen several oaleites of this
^H kind occupying the anterior tuberosity of the tibia in adolescents, and
^H none of them ended by suppurating.

^H I therefore told you that, very probably, after a week of rest and
^B oare all danger would have disappeared. •

^H All things have gone on as we expected. The treatment consiateA
^f simply of poultices and rest in bed. For several days the young maa'
has had no spontaneous pain and suffers very little pressure; I maW'
consider him cured. Still the anterior tuberosity is enlarged, and 6,
think it will remain so. For, indeed, as I shall often have occasion
to show you, it is very common to see the hypertrophy which we oaU
hyperostosis follow osteitis, whatever may have been its course, that
is to say, whether the termination has or has not been by suppuration,
and whether the inflammation of the bone was spontaneous or trau-
matic. You will scarcely see any disappear without leaving hyper-
ostosis, except the superfi.cial swellings which have chiefly occupied
the periosteum, as is the case in syphilitic or rheumatic ostea-perl^

NON-anPPURATIN'G EPIPHYSART OSTBITIS.

^^L'&'^t'tiS' But in the cases in which the osteitis, whatever may have been

^^B its origin, has been interstitial, that is, has occupied the compact and

^^m cancelioas tissues to a certain depth, and in which the phlegmasia

^^B has been accompanied by an increase in size, you may expect to see

^^V the hyperoatoisis persist, and to preserve a tendency towards suppura-

^~ tion when the original osteitis has been suppurative, but, on the other

hand, not to have thia tendency when the primitive osteitis has not

terminated in suppuration. Consequently in the case of this patient,

flUhough I see the hyperostosis of the anterior tuberosity of the tibia

persist, and though I know that for a certain time and until the eom-

pletion of ossification lie will be exposed to renewals of this paini:

especially if there should be another contusion, I do not think he {*:■

threatened with suppuration of the bone. If he was going to have itj.

he would have had it this time.

II. The other patient, who has been here two dnys, is n young man
venteen years old, who tells us that three months ago he fell upon
B left hip, and that since that time, without having been entirely'

[laid up, he has had constant dull pains in the region of the trochanter!
These pains have only recently increased, walking finally became SO
difficult that the patient was obliged to use a cane and enter the '
pital.
When I examined him I asked him to indicate the precise seat of
is trouble; he placed his hand upon the upper and outer portion of
his thigh over the great trochanter, and told us that the pain often
extended to the knee. There is almost no pain while he is at rest, it
appears especially while he is walking or standing. I pressed with
my hand upon all the outer portion of the thigh, and you saw that
this pressure caused pain only over the surface of the great trochanter,!
There we find an ill-defined swelling which at first did not appe»»'

I very marked, but which is easily recognized when you compare the
two trochanteric regions, making -the patient lie first upon one side,
then upon the other. Trying to discover with the hand the exact
position of the swelling, you saw that it was not in the subcutaneous
cellular tissue, and was not due to an eft'usion into one of the two
liynoviai bursee of the region, for there was no fluctuation. In short,
it seemed certain that the part which was swollen and painful on
pressure was the great trochanter itself. There is no fever, and the
general condition is good,

With what affection have we to deal? The pain, which has already

lasted a long time, the lameness which followed it, the diffuse swelling

of the upper portion of the thigh, all give at first the idea of a cox-

fllgia. But, the patient lying squarely upon his back, I told him to

, lift his heel from the bed, to raise his foot well without bending the

■ knee. He made the movement easily, and while he made it I fell
I'with one of my hands placed upon the creat of the ilium that this
Itione did not budge. If it had been coxalgia the elevation of the
I'heel would have been slower and more difficult, and would have been

■ accompanied by a movement forward of the ilium, a movement due
|to the fact that, since in this disease the articular surfaces are rendered

uoiovable by muscular coatractiou, tha nkuvements no lunger take

— !:«

rM BDRGIOAL 1HSEA3K3 OP rOlTTH.

^m place in tbe articulation of the hip, but in those of the pelvis wilh

^1 spinal column, and in those of the lumbar vertebrEs. Then taking 1

^m of the atikle and Sexing the leg upon the thigh, and the thigh upon

^M the tniuk, I felt that I coinmuDiiiated these movements easily and

^M withuut experiencing the reMiatunce which is met with in coxalgia,

^H becaui^e then the head of the femur and the cotyloid cavity are no longer

^m movable upon one another. Then comparing the height of the spines of

^B the ilium I found that the one on the affected side v^as not lowered

^p ns it would have been in case of coxalgia, and finally, carrying ray

hand to the lumbar region, I did not find there the bend whiuh ia

usually found in this latter disease. The result of my examination

then authorized me to declare that the affection was not a coxo-femoral

I arthritis, and before reaching this decision I had made the examina-
tion with all the more care because the patient had been sent to me
by a physician with a note indicating that he feared the beginning of
a coxalgia.
On the other hand, the existence of pains radiating along the thigh
might have given rise to the idea of a sciatica. But you saw that
these pains were on the outer side, while in sciatica they are espe-
cially in the posterior portion of ihe thigh ; that pressure caused them
in a region (that of the great trochanter) where they are not found in
sciatica, and that finally they were developed while walking, and
were not felt when the patient was at rest. Now the principal cha-
racteristic of the pains of sciatica is that, although they are sometimes
exaggerated during a walk, they appear spontaneously during rest,
and even during rest in bed. Consequently there was no reason here
to believe in the existence of a sciatica.

You will sometimes hear me apeak of a disease, difficult of diag-
nosis, ivhich occupies the sacroiliac symphysis, and bears the name
of socro-coxalgia. I had also to throw out this disease, because of the
localization of the pain in the trochanteric region, and ils being
awakened by pressure upon this region.

Further, there was no symptom of hygroma, and in addition I knew
there was a swelling over the great trochanter,

I recalled the fact that Velpeau had indicated in his lectures osteitis
limited to this prominence, and I remembered having met adolescents
who had presented symptoms analogous to these,

I thought, then, that we had Ui deal here with a subacute osteitis of
traumatic origin, an osteitis developed, like that of the anterior tube-
rosity of the tibia of which T have just spoken, upon or in the neigh-
bourhood of an epiphysis. For you kuow that the great trochanter
develops from a special complementary point of ossification, and that
it remains until the age of from 20 to 25 years separated from the
rest of the bone by a cartilaginous line. There has occurred, then,
in my opinion, in this great trochanter, that which occurred in the
anterior tuberosity of the other patient. It has been bruised at a
period when its nutrition was excited by the needs of ossification, and
this couiusion has been followed by a phlegmasia which began, per-
haps, in the epiphysary cartilage, perhaps in the bone itself. For we
cannot determine the starting- puint by clinical evidence, the only
I evideace which we have at our disposal. ^i^^^H

h^l

NON-SDPPtJBATlNG EPIPHT8ART 08TEIT19.

rl do not claim that a similar contusion would never be foHowefl by
trochanter! tis in an adult; I only say that that is much more rare,
and that the affection is seen chiefly in adolescents and in those
regions where are found the epiphyses ; that is, bony extremities still
separated From the rest of the bone by a cartilaginous line.

II now ask myself, gentlemen, what is to be the result of this tro-
chanteric osteitis or subacute trochanteritis. Certainly we may hope
that it will behave like the tibial osteitis of which t hsve spoken ;
that is to say, thut after a rest of a few weeks it will terminate without
suppurating, and will leave behind it a slight hypero3toais. But I
must say that I fear suppurulioo mora in this than in the preceding
case. For the osteitis has already lasted three months, and has
steadily grown worse since the beginning. The patient is thinner
and paler. Wiihout being distinctly scrofulous, he nevertheless
shows us the attributes of the lymphatic temperament, among them a
certain aptitude for suppuration, I do not expect the ultimate de-
velopment of one of tho.se acute and putrid suppurating oateites which
, may be followed by purulent infection. It is rare for osteitis to take
on this acute form in this age, when in the beginniog and for a cer-
' tain length of time it has been subacute.

I shall not fail to show you examples of acute epiphysary osteitis
n adolescents, and to point out that they were such iu the beginning,
ind were not preceded by a slow, dull inflammation.

Our present patient is threatened rather by that variety of slow
suppuration which ieiida to caries and necrosis.

Ho would then find himself in the position of a young man whom
I showed you last year, who bore two fistulse in the trochanteric
region. The probe passed through each of them to the bare and
roughened surface of the great trochanter, and announced the exist-
ence of that variety of suppurating osteitis which ought to end in the
, elimination of one or more sequestra, and which we call necro.'^is. I
3id not feel the probe penetrate deeply enough, breaking its way
through the bony lamellos, to admit the existence of interstitial sup-
purating osteitis of the cancellous tissue, known generally as caries.
But it is probable that this form may also occur in certain subjects
after subacute trochanteritis. I cannot give any example; for,
since diseases of this kind are not very common, I have not treated a
sufficient number of cases to have seen all the forma.

The important thing for our patient ia that this osteitis is not so
necessarily destined to suppuration aa it would be perhaps" in child-

Ihood, and even during adult life (in case, of course, tertiary ayphilia
is not involved), and that by reason of his age we may avoid this
mode of termination.
What have we to do to obtain that end?
Of course we shall keep him in bed and not allow him to get up
under any pretext.
Furthermore, I shall apply compression by means of a layer of
cotton batting, kept in plaue by a figure- ofeight bandage, the loops
of which will pass alternately about the upper half of the thigh and
the pelvis. This ia the bandage which you know by the name of

BUBQICAL DISEASES OP YODTH,

ica, but its femoral portion will extend a little lower upon the
thigh than in the ordinary spica. I shall renew this dreaaing every
third or fourth day.

At the same time I shall give the patient three or four tablespoon-
fuls of cod- liver oil daily, and prescribe five ounces of vinde qui oquina
to be taken before breakfast, and the same quantity before the evening
meal, and I shall nourish him aa well aa possible.

I should like also to protect him from the exhaustion of mastupS
tion ; for patients of delicate constitution, in whom we have reason |
fear suppuration of the bones, find in excesses of this kind an increaS?
of their debility and its consequences. In private practice I adviae
the parents not to leave the young man alone, to distract his attention
and occupy him aa much aa possible; in the hospital this care j
iinpoasihle, but I shall give all the advice necessary.

We shall continue this treatinent for a month, and then atop t
use of the bandage and allow the patient to get up for a short tid_
each day. K I find that he does not aiifler I shall make him walk "
little more every day, and if he still does not autier I ahall consider
him cured.

If, on the other hand, the attempt showa that a cure has not been
obtained, I shall advise him again to remain in bed and ahall make
uae of some revulaive on the skin. For thia I shall have to choose
between blisters, caustics, and punctate cauterization. I have no
absolute preference for any one of these, for thus far my experience
baa not demonstrated the superiority of one over the other — neverthe-
leas, punctate cauterization is the one which I shall use if after a
month's rest in hed this young man still sufi'era a little on pressure
and when walking.

(I'unctate cauterization waa applied, forty paints, with a small iron
rod, at white heat, while the patient was anteathetized with chloro-
form. Six weeks afterwards all pain had disappeared and the patient
was considered cured. He left the hospital, and has not since been
seen.)

uina
nin^^^

)nl^^H

I tion

LECTURE Vr.
. HYMROSTOSrS OP RIGHT FEMUR. 11. NECROSIS OF LEFT TIBIA.

Some ooiiaiderationa npon diseaaefi of the skeiBton
oent — I. HyperostoBis of tba femnr and ancliyloai
suppurating epfpliysarj osteitis — Pre»h iDtlninma
lug in Buppuratiou— II. Neomsis of tlm tibia fono'

I tlie

Uif adolsB-
of the knee fnllowiiig a Dou-
irj attack, aUo not tHrininat-
uppiirating epfphjaary

D ate itia — Fresh luHaminatian — Movable anperfiuial aequcalrani.

vagiuatiid eeqaestrum — Long durtttiou of tlija ueorosia prababl/ until adult life.

Gentlemen: Chance has recently brought together in our wards
two patients suffering from the late conaequences of the disease which
you often hear me speak of aa acuie epipbysary osteitis qf youth.

But first of all, I must make an explanation.

^H In point!
^P have nevei

^" .1. A

HYPEROSTOSIS OF HIGHT FBMUR.

In pointing out to you the diseasea oF youth I do not mean, and I
have never meant to say, that these diseases belong exclusively to
youth, and are not seen at other ages; I wished to say that they were
more frequent during youth, and that, as a rule, they took on at this
age uharacters different from those which are seen in the same lesion
at other periods of life.

I have been criticized upon this subject. Especially with reference
to acute epiphysary osteitis, it has been objected that this disease is
seen in childhood.

I knew that perfectly well, but T also knew two other things: first,
that it is less frequent than in adolescents ; second, that it is also leas
dangerous.

I knew also, in the third place, that osteitis of adults does not take
on spontaneously, and without the intervention of aoUtions of con-
tinuity affecting at the same time the bones and the soft parts, those
dangerous forms which occur almost spontaneously in the child and
in the youth. However, to enable you to decide the question for
yourselves I give you the statistics published upon the subject.

Dr. Cullot, author of a very good thesis,' givea the following t;ible
of the ages at which epiphysary osteitis appears : —

M. S^zary,' who collected, also, for his graduating thesiij, H2 case.'},
of which 67 were between the ages of 12 and IM, finds an average of
13 years. But the average of S3 cases observed by himself at the
H6lel-Dieu of Lyons was 16 years,

Klose's 13 cases average 13 years.

M, Chassaignac* mentions 23 cases, of which 4 were between 9 days
andlO years; 15 from 10 to 18 years; and 4 from 18 to Sti years old.

From all these figures, which have been reproduced in an excellent
ihesis by Dr. Sal&s,* it results, gentlemen, that the end of childhood
and the first years of adolescence, until about the age of 19, are the
periods of life during which appear, chiefly, but not exclusively, the
diseases which we are about to consider. They are most often met
with between the ages of 12 and 18.

And here let me say that in speaking of adolescence, we do not give
it perfectly defined limits, sometimes it is considered as beginning at
12, sometimes at 13, sometimes at 14 years, and when we clinicists
speak of the diseases of adolescence or youth, and especially of those

Bsauiguao, Traits de !& Siippnrntion at da Dminage, vol. i. pngx 413.
I&t, Db Ib MBroba et dn Traitemeiit da L'Oiitfio-perioitUe diH-Bpipliysaire Biip-
Thcaa du Faris, 1871.

SDKQICAL DISEAaES OF YOUTH

I
I

■wbicli we attribute to a derangement of nutrition while the boH'
lengthening, anil ut the moments of that exaggeration of vitality whi
prepares the union of the epiphyaes, we know that this exaggeration
presents nmneroae individiiiil varietias. In soma patients it occura at
12 or 13, in others at 16, 17, and IB years of age, in some the growth
ia progressive and slow without any excess of activity more marked
at certain moments; in others, on the contrary, this excess of activity
appears several times and irregularly. In short, a child 11, 12, or IS
years old may be adolescent as to hia epiphyses, but not as to the rest
of his body.

At the time when I published my first work upon this subjt
pathologists and cliniciats were accustomed to describe diseases of
skeleton according to the data of pathological anatomy and physiology
without considering age, and witliunt warning practitioners that such
a form of acute osteitis appeared especially at such or such a period
of life. My object was to call attentiun to this subject, and to show
the relations between the age and growth of the skeleton on the one
side, and the forms of spontaneous osteitis on the other, and I have
with pleasure that subsequent works upon this subject have
followed the path wliiuh I opened. I made certain reservations
relative to childhood, because, not having practised in the children's
hospitals, I could not know wliat took ])laoe in the first and second
periods of childhood ; I insisted particularly upon the frequency with
which I had observed the diseiises to occur in adolescents as compared
with adults.

Since then my colleague, M. Giraldfia," has well shown that children
may be affected, especially at the end of childhood, or, if you prefer,
at that period of life which is between the end of childhood and the
beginning of adolcMcence. The excellent works of Messrs. Garnet*
and Louvet,* and those already quoted of Messrs. Sezary, Cullot, and
Sa!6s confirmed these assertions of M. GiraldSa and myself, and
enabled us to draw practical conclusions from this simple l"act: the
latter part of childliood and adolescence are exposed to forms of
spontaneous acute osteitis which are seen much more rarely at other
ages.

Let ua now turn to the two patients with reference to whom T
thought it necessary to present these preliminary considerations.

I. The first is a young man 19 years old, pale, with chestnut hair,
but with well-developed muscles, showing no scars upon the neck, and
giving no indication, past or present, of tubercular affection. He tella
us that at the age of 13J years, without ajipreciable cause, or after a
blow which he does not remember very distinctly, he had severe pain
in the right knee and the lower part of the thigh; that he was very
ill at this time and had much fever ; that after a few weeks an abscess
was opened on tlie inner and lower part of his right thigh, which
suppurated for a long time, and finally closed without the e.\pulsion

< GoBsalia, ArahirHS g^Lieniles iIh Md.louiiii!. 165S, tome ii. p. 518.

■ Qlrald^a, Leqnna oliiiiqaeH Btir lua Maladiua uhirargiuales da I'Enfanae, [>. uSB,

" riiiniet, Tlifeses r]e P-iriB, 1863.

* LoBTBt, FScioMtltB phlBgtttoniime dlffiMB, Thiaw da Paria, 187S.

]

rest

i
I

HTPEROSTOSIS OF BIGHT FBMCR. Sfl" «

of any sequestrum or rragmenta; that at laata cure toitk place, leaving
the knee slightly flexeii and immovable, and compelling tlie patient
to iiae a cane and a shoe with a heel three inches high.

A week ago, without apparent cause, ho again began to sufTar a
little in the lower part of fain thigh and knee, and. being no -longer
able to walk and work at his trade of ahoemaking, he applied to ua
for treatment.

We find the knee completely nnchylosed by fusion, the femur and
tibia united at an angle 'if about 40 degrees — what we call angular
anchylosis of the knee. There ia no notable swelling at thid point,
and only a little heal.

Above the knee the muscles of the thigh are evidently smaller
th.an those of the opposite side, but yet the lower third of the
limb appears a little larger, and on graaping it with the whole hand
I feel a very hard circular reaisiance which gives the idea of n femur
much more volnmimiug than the other or a normal one. I know
that one may be deceived by a lesion of the muscles, which I have
found in two autopsies, and which has been well described by M.
Aug. Ollivier;' I refer to atrophy of the muscles, with transformation
into a very dense fibrous tissue, which cannot he elearly distinguished
from the femur by the hand examining through the skin. But here,
as the apparently bony swelling is very large, and as it involves the
condyles of the femur themselves in points where there are no ^
muscular fibres of the quadriceps, I infer that the tumefaction 000%
pies, if not the whole, at least part of the lower third of the femur, .fl

Notice also that this swollen portion is painful spontaneously, and
upon pleasure. As there is uo phlegmon which uould cause these
pains, we may attribute them to the femur ; now at this age the bones
become more frequently and more easily painful when they are
bypertrophied than they do in subjects in whom this condition does
not exist.

Furthermore, there is no fever, no notable alteration of health, and
the pains, more severe when the patient is standing or walking, have
not so far been sufficient to prevent his sleep.

The diagnosis, gentlemen, presents two questions; What is thi
young man's presentdiaease? aud What was the former one which hi
evidently prepared this one?

As to the present disease, it is composeil of combined lesions that
f«re already old, anchylosis of the knee, and hyperostosis of the femur,
with concomitant muscular atrophy. These three lesions are irre-
meiliable, and they are not what has brought the patient to the
hospital. But there is further a recently added pathological condition,
a subacute and painful osteitis in the region, and perhaps also in
the thickness, of the liyperostosia. If we did not possess the antece-
dents relative to the aoute disease six years ago, we should have to
see whether this considerable swelUng'of the femur were not due to
sn osteo sarcoma. But with these antecedents, and in presence of the
iact that for several years the swelling, instead of increasi

< Aug. Olllvicr, Tlitett Je CuiicQUts poor l'Agi%atioti, ParU, 18119,

'au 8DBGICAL DISEASES OF TOUTH.

diminished, there is no reason to dwell very long on thia dia_
■and remembering, furthermore, that byperostoaia ia often tlie conaij
quence of osteitis of the long bones, we need not hesitate long
subacute osteitis or fresh inHammation in an olil hyperostosis.

As to the etiological diagnosia I have nothing in particular to poiM
out.

I shall tell you hereafter that in adults non- suppurating osta
periostitis is often due to general causes; rheumatism, syphilis, or'
feeble state of the constitution similar to the scrofula of children,^
sort of acquired or late scrofula. Hera none of these general c
can be accused. The fresh inflammatory attack appears to have hat
spontaneous, or if tliere has been a traumatic cau.se it has been "j.
slight contusion of which the patient has preserved no recollectiorf;
Porhaps the age of the patient and the exaggerated nutrition of the
bones have had some influence. It is true that the union of the
inferior epiphysis of the femur was completed long ago, for one of the
consequences of these osteites of adolescence is to fasten the union of
the epiphysis. Nevertheless, I think the age has had something to
do with the etiology; for you will often see in adults hyperostosis
eonsecutive to simple or compound fractures, and you will notice
that the inflammatory attacks, necrosis once ended, seldom occur so
lat.!.

Let us now consider the other question : What was the original
affection, the traces of which we see here, and of which the present
symptoms are a remote consequence?

From the information we have gathered and from the analogy
belweei> what the patient has told us and what we have observed in
a certain number of adolescents, there can be no doubt. This young
man was affected at the end of childhood with that disease of which I
spoke at the beginning, acute osteitis, ending promptly in suppura-
tion ; and as this osteitis appears to have been spontaneous, or, if
traumatic, to have been caused by a slight injury, I feel aura it was
one of those osteites which begin in the epiphysary cartilage itself, or
in one of the adjoining surfaces of bone, and of which the predisposina;
cause is the work of ossification. I cannot say whether the periosteum
alone has suppurated, or whether the compact tissue also, and espe-
cially the medullary substance, both that of the caual and that of the
cancellous tissue, have participated.

I am convinced that in many eaaea of thia kind all the constituent
parts of the bone share in the inflammation, and that there ia osteo-
myelitis at the same time with periostitis. But whan the patient
survives, it is very difficult, if not impossible, to show whether the
deep portions of the bone have suppurated, as well aa the superficial
ones, or whether the osteo-myelitia has been non-suppurative, the
periosteum, on tlie contrary, having been attacked and even destroyed
by the suppuration. I shall hereafter have occasion to return to thia
subject; today, I say that there has been suppurative osteitis, at least
on the surface, and general osteitis, probably non-suppurative, but
piesenting the fonti dccribed by Gerdy as hypertrophying or condensing,
Thitj oateititt dues not seem to have beau ueurotiu, as it often is in like

N£CROSIS OF LEFT TIBIA, ^^^^^1

lis respect it is exceptional. But it has got well, lenvitig ^^M
I ypernatosis, which is the almost inevitable consequence ^^1
of hypertrophving osteitis when it occupies the compact tissue oF the
long bones; and as the peculiarity of this hyperostosis is to preserve,
for a certain length of time after its formation, a tendency to sub-

Iflcute or chronic inflammation, and as this is more marked during
ildolescence, we find in it the origin of the recent inflammation which
!bo day torments this young man.
i Now, what should he our opinion as to the consequenues of this ^^
disease ? What we have to fear is suppuration. It is true that this ^^M
may possibly occupy exclusively the cellular tissue, without partioii ^^M
■jwtion of the bone in the process, and form what Gerdy called a ^^H
neighhouring abscess (abcfes de voisinage). Such an abscess woulct'^^|
end like a simple one, without ultimate necrosis. But if the hyper- ^^H
ostosis itself shoald suppurate, either on the surface, after desiruutiofi ^^H
of the periosteum, or in the interior, that would indicate that a por- ^^
tion of the hypertrophied femur was necrosed, and then our patient
would be condemned to long suppuration and to the fistulra which
precede llie elimination (always very slow) of the sequestra or mortifieil

Biarts of the bone. Considering all things, I do not much fear thfa ^^M
Brniinution, and for the following reasons: the conscitution of thft^^H
latient is not broken down, and as the osteitis escaped necrosis when ^^M
t was acute, as the present age exposes a little less to it than the one ^^

3 the present age exposes
which the disease of the femur began, and finally, as the inflani'
matory symptoms are moderate and subacute, we have the right to
hope that the present attack also will end by resolution, and th»t the

Kalient will continue to escape necrosis, to which ha will be so muoti
he less exposed as be grows older.
To favour this fortunate termination we have only a very aimpltt
reatment to institute.
We shall keep the patient absolutely quiet, and advise him not to
fuik BO long as there is any pain. We shall cover the affected pari
rith pouJliees, and prescribe 8 or 10 grains of the iodide of potaasiunt
laily. If the disease lasts more than three weeks longer, I shall
irobably prescribe a blister, perhaps punctate cauterization. But I
loubt if these measures are useful; for of two things one: either
suppuration is inevitable, and then it is too late to have recourse to
them, or resolution is to take place, and then rest and simple means
BUfEce.

, The other young man is 17 years old, and comes to us for the

md time. The first time, two years ago, he was suffering with

!Ute epiphysary osteitis of the right tibia, in its lower portion,

found iiira very ill, with much fever; and the aftection' ended

1 large abscesses, some of which communicated with the lower

portion of the denuded bone, and the others seemed to communicate

with the tibio-tarsul articulation. In a word, it was one of those

p«eriou3 cases, such as I have described,' in which the suppurative

■ rOsWite ipipiiysniro das Adolesoouta. (Aruliivaa da MSi.

^B«ecoi

^^^Ut(

^ppP~e

I
I

■ 42 aUHfilCAL DI3EAaK3 OF YOUTH,

inflammation is propagated from the epiphysis and the bone iif the
neigbbdurlng arliculaiion. Fearing for the life of the youth, and
seeing him exposed, if perchance be ahould not die, to a neurosis
which would torment him for many years, I proposed amputation,
but bia parents refused absolutely. The suppurating osteo- myelitis
and arthritis did not assume a form sufficiently putrid ti> cause puru-
lent infection ; the patient also escaped becticity ; and when he left
the hospitiil, after six moniha' stay, he bad the tibio-tarsnl articulation
anchylosed, without persistent necrosis of the astragalus, and pre-
served at the lower pari of the leg, two fisiulaa which suppurated freely,
and through which the probe reached the tibia, which was denuded
over quite a large surfuce and notably byperostosed. He walked,
furthermore, with the aid of crutches.

The subsequent course of the disease was auch as it is in moat of
the young patienta who survive acute epiphysary osteitis ending in
suppuration, auch, for example, as it was in the case of the young
man whom you saw for a long time in our wards last year with ne-
crosis of the fetnur consecutive tn an osteitis of this kind. Suppura-
tion has continued, and he has not been able to lay aside his crutches.
New pains accompanied by fever appeared twice, and each time a
new absceaa formed and a fragment of bone was e,\pelled.

A week ago a new inflammatory attack occurred, which confined
the patient lo his bed and forced him to seek admission to the hos-
pital. You saw that the lower part of the leg was swollen, hot, red,
and painful. The tibia is considerably hypertrophied, and the four
fistula) which lead to it furnish a large quantity of nou fetid pua.
The probe passed through these fistulre reaches a denuded surface, and
I showed you that, placing a probe in contact with the bone through
one of the inner fistulie, and passing another through the lower one,
and pressing with it upon the corresponding ]>ortion of dennded
bone, I transmitted the movement to the first probe. Thence I con-
cluded that a portion of the bone was necrosed and separated from
the rest, that is, that there was a auperfiuial movable sequestrum.
Exploring with the probe upon the other side, I felt upon the
denuded surface an opening through which the instrument penetrated
about half an inch and enabled rne to feel another denuded portion,
which was not movable, but which appeared to me deatiiied to
become so, and to form what is Cidled in the description of necrosis
an invaginaled aequeatrum.

The present affection, then, of this young man is a persistent
necrosis of the hyperostoaed tibia, with superficial movable seques-
trum and invaginaled sequestrum not yet movable. You know
that hy the name necrosis we designate a mortification of the
bony tissue, that this mortification, afteoting more often the com-
pact than the cancellous tissue, is one of the moiles of termination
of suppurative osteitis, and coincides quite commonly with hyper-
trophy and condensation, so that these three things — suppuration,
hypertrophy, and mortification — idmost always go togetiier. Un-
doubtedly Gerdy'a condensing or hypertrophying osteitis can occur
Jji ihe compact tissue of the long bonea without suppuratioo and

NECROSIS OF LEFT TI]

ttl

■jthout necrosiB. I s!iowe<l you an example lately in an a'iolea-
■nt, and I shall often show you othera in adults. But when thia"
ileitis ends in suppuration, it is at the same time hypertrophyii _
necrolio ; it ia what you see distinutly in thia case, and what
.,„_ will also Ree from time to time in adultp;but whili? in the
latter, suppuration, hypertrophy, and necrosis occur, especially after
extensive traumatic lesions in whi.!h there has been open wound and
fracture, or, if you prefer, exposure of the bone to contact withi
they have occurred in this young man, as is generally the>
adolescents, without external wound, without preliminarj''
ixfiOHure, and a'ter an osteitis either purely spontaneous or conaeca--
' 'e to a slight contusion without rupture of the skin.

What will he the ultimate course and what the consequences of

this young man's disense ? As for the present inflammation, it will

cease in a few days, perhaps after formation of another absces3,an d

the patient's life is not endangered — first, because the fever i»-

oderale, and, according to our experience, is not likely to augment',

id lake on a dangerous character; and secondly, because it is tb*

that exacerbated chronic osteitis in an old hyperostosis doeBf

lot take on the dangerous forms of primitive acute suppurative'

teitis.

To what is due this difference in danger between suppurative
iteitis preceding hyperostosis, and osteitis consecutive to the latter,
hen the predisposing cause of age still exists? This ia perhaps
lifReuIt to explain. I atiribute it to differences in structure. Before
typertrophy all the cavities of the bone are filled with fat, the sup-
puration of which, as I have told you, contributes greaily to give to
oateo-myelitis its well-known danger; moreover, there is the epi-
physary line in and near which osteitis takes on in the uduleseent th*
intensity and gravity with which you are acquainted. After hyper-
ostosis has occurred the medullary cavity is filled up or greatly
diminished, at least in the great majority of cases, and consequently
there remains but a small proportion of fat. The cavities of the
cancellous tissue and the eanalieuli are also diminished and lose most
of their fat; hence, as the principal element, suppuration of which
causes the danger of osteo- myelitis, is reduced to small proportions,
the reappearance of the latter is leas dangerous. Furthermore, the
epiphysary line has disappeared by ossification, another reason for
the mildness of consecutive phlegmasite. Notice this, gentlemen : the
anatomical result of osteitis is hypertrophy, and with it a certain
tendency to relapse ; but at the same time it diminishes the number
and extent of the bony cavities in which are distributed, amidst the
fat, the bloodvessels destined to nourish the bone — hence a certain
tendency to mortification in spots, that is, to the necrosis which so
often ensues. Con.'iequenily, if the favourable result of the anatomical
changes caused by the primitive osteitis is to preserve against danger-
ous relapses, there is yet this other unfortunate result of keeping up
prolonged suppuration and necrosis. I say, then, that this younj^
man, in all probability, will nut die, and will nut even be dangi
«u^y ill.

?le!*- ^M
thia ^1

I
■

SURGICAL D13EA8E3 OF TOUTS.

In addition, aa hia tihio-taraal articulation 13 obliterated, we have
not to fear a propagation of the suppurative phlegmasia to the synovial
membrane; but the necrosis will last for a long lime yet, probably
for years. Undoubtedly another sequeatrum will soon be expellecl,
but there is still another in course of elimination. There will proba-
bly be fresh inflammatory attacks and other portions necrosed which
will keep up the suppuration, and that may indeed last until the
patient shall have outgrown the age during which the predisposition
exists. I know that in this respeut there are some varieties, that in
certain subjects the new attacks of osteitis cease to occur long before
the end of adolescence, notwithstanding the continance of the hyper-
ostosis, and that sometimes these rehipses and the continuation of the
necrosis are seen in adults. But since we have to funn a prognosis
we should do it in accordance with the facts furnished most frequently
in our practice. Now I noticed long ago that necrosis and persistent
suppuration of the large long bones, especially those of the lower
limbs, which have been previously hyperostosed by an acute spouta-
ueous osteitis, are seen especially during adolescence, and end with
it. The patient having become adult preserves only the articular
deformities, the hyperostosis, and the diminution of tlie muscles caused
by the original disease.

TreatTnenl. — We shall make an incision to remove the superficial
movable sequestrum which we felt, and at the same time make the
explorations necessary to discover if by chance there is another ; then
we shall keep thepatientin bed, apply poultices, and give him tonics.
In a few weeks he will leave us, atill preserving the fistulae and the
Ruppuriition, and we shall have no other advice to give him than to
avoid such fatigue and contusions as might cause another inflamma-
tory attack.

Some one asked me this morning why I did not propose to this
young man to relieve him of hia present infirmity and his chances of
relapse, by amputation of the leg. These are my reasons; first, am-
putation would endanger his life, which, in my opinion, is not threat-
ened by the present lesions; and second, I have reason to hope, as I
have juat told you, that the infirmity ia temporary and will disappear
with adolescence, and that when from 25 to SO years old he will walk
more easily and will have no more pain and suppuration. In short,
he will be cured, with a tibia a little large and an anchylosed articu-
lation which will trouble him much less than an artificial limb, and
will certainly be more agreeable to him than a mutilation.

ACOTB EFIPHY8AHY 0BTKITI8.

LECTURE VII.

ACDTE EPIPHTSaRT OSTEITIS OF THE LEFT FEMUR, WITH StTPPURATINS
ARTHRITIS OP THE KNEE. AMPUTATION OF THE THIGH.

Dflgoription of tlie piaos — Diffionlty of dBtermiuIng whether the periostenm is Btripped
off or daHlroyed— Snppuratiou and partial disappearancB of tha epipliyaary car-
tilagtt— Diffase suppuration of tha canoollous lisaoH and the medullary onual—
Pus <n the arti CD 1 a tion— Different names gtren 10 the d i bo ase— Preference for
that of aoute epiphyeary oBteitia — ^Tlirea varieties of this dieeaas : 1st yariely,
eilemal perioatilia without doatmetion of the periostHnm ; 2d variety, snperD-
^^ elal oaten-perioBtliifl with deslrnotion of the perinstenm; 3J variety, general
^B deep osteitis— DitSoulties and interest of the diagnosis of these thrtre varieties.

^pGENTLEMKN: I show you here the specimens coming from an
Tmputiition of the thigh, which I performed] the Jay before yesterJay,
upon a youth 16 years ohl who enlertiii the hospital for a suppurat-
ing osteo-arthritia of the thigh and knee. The patient was taken
suddenly, three weeka ago, after a long walk, with high fever which
■was at first thought by his physicians to be typhoid fever. But soon
a painful swelling appeared at the lower end of the right thigh and
the eorresponding knee; then deep flnctnation was felt, and it was in
this condition that the boy was brought to as after he had been ill
twelve days.

We at once felt deep fluctuation on the outer and inner sides of the I
lower part of the thigh, and also very distinctly in the joint itself, ^
which was notably distended.

The day after his admission I made two free incisions, one on tha- I
inner, the other on the outer side, and passing through the vastus- 1
internus and vastus externus I reached a large purulent coUectioa' [
and evacuated a pint of creamy, thick pua, slightly fetid and mixed I
with drops of oil. Passing my finger to the bottom of the nbeess I 1
felt the femur denuded on both sides. The articulation was not |
emptied at first, for by pressing upon it I made no pua escape throug
the incisions. I was not then sure that the arthritis, which was I
evident, had gone on to suppuration. The patient was a little. I
relieved, but he remained unable to make any movement without j
suftering a great deal in the knee, which was slightly flexed, tho' i
limb resting on its outer side; and the fever continued with 130 I
puiaations and a temperature of 102° in the morning, and 103^ to |
104° in the evening.

The third day, by pressing upon the knee, I diminished ita size ]
and caused a quantity of pus to escape by the inner incision.

There was then no longer any doubt the abcess was articular as
well as oasifiuent. Knowing then from my own ex^Wft%>ia, ^tvJi.
«af>eaiall^ from the /acts communicated U) the .fc.Ra.\om\»M\'i*i^>a\-"lC^'^

SURGICAL DISEASES OF YOUTH.

1858, by mv colleague and Triend, Dr. Leon Labb^, at tViat time my
interne at the HGpital Cochin, tbat this affection is followed by a
large proportion of deaths, either by pvEemia or by hecticity, and by
long suppuration and necrosis when (ieath does not take place, I pro-
posed ampulatioti to the patient and his parents as a means of
diminishing the chance of a fatal termination.

The operation was performed, and examination of the affected parts

ivea us the following details: —
T first show you the cavity in the thigh, which contained the pus;

; surrounded fuur-fiftbs of the lower quarter of the femur, not
reaching its posterior part. The vastus externus and internus
muscles were stripped from the bone and formed the outer wall of
the cavity, the inner one being the anterior and lateral faces of the
femur. This bone is, as you see, without periosteum. Whether the
latter was destroyed, or stripped oS' with the muscles, I cannot say.
You notice, however, that if we seek it on the under surface of the

lusoles, near the upperlimit of the lesion, we do not find it distinctly.

; appears that its continuity with the rest of the bone is interrupted,
and I do not 6nd on the muscles a fibrous layer resembling the
periosteum. I see only a detritus which appears to belong to the
muscle itself In a word, I do not find distinctly a simple stripping
off of the periosteum, and 1 believe rather that this membrane has
disappeared by absorption or by gangrene and prompt elimination.
Ill almost all casps of suppurating osteitis with denudation yon will
have this same difficulty in determining whether the periosteum is

lerely stripped oft' or whether it has entirely disappeared.
At the surface of the denuded bone we see little else than an
enlargement of the vascular cnnuliculi, which, on the contrary, would
have been narrowed, and some of them closed, if the patient had
lived and hyperostosis had occurred. We find that the peripheral
portion of the epiphysary cartilage has disappeared, so as to leave a
groove in its place. Tliis groove is filled with pus, and evidently
formed part of the purulent cavity. In order to examine the rest of
the bonewe have sawn it vertically and from in front backwards, so
that the section reaches the articular surface between the upper
insertions of the crucial ligaments. You see that the marrow above
the epiphysis is red, infiltrated with blood, pus, and plastic material
in the alveoli of the cancellous tissue and in the lower portion of the
medullary canal, the lesions of which end about an inch below the
point of amputation.

The epiphysary cartilage is destroyed in places and to an extent
greater than was indicated by the groove we saw at the surface.
Beddish, sanious pus is seen at the points where it has been destroyed.
Above and below the cartilage the bony alveoli are infiltrated with
pus, and the surface of section has a red, vinous color.

Finally, the articulation is filled with pus, the diarthrodial cartilage

of the femur is destroyed here and there, and can be easily peeled off,

exposing the compact nub-cartilaginous layer, itself eroded in places.

The pun contained in the articulation communicated with that of the

•tbigh through &n irrejfular opeuiug m vW 8.QtAi\ui; ^cL of Uia

ACPTE BflPHYSARY OSTEITIS.

47;|

up- 1

synovial membrane near the eilge of the cartilage of incnistatii
to which, Furthermore, the periosteum is destroyeil. It seem
the synovial membrane adjoining the cartilage, and at the point,
where it covers the periosteum of the groove above the condyles, hi "'
also shared the destruction, so difficult to explain, of the periosteum.'
The diarthrodial curtilage oF the tibia and the semilunar inter-
articular cartilages are not affected.

Id presence of thece lesions yon can understand the different
names wbich have been given to the disease of which they are the.
expression. These names are not recent, and the difQcuUy about
establishing one definitively was due to the fact that our predc^ssora
had not studied the disease, and hud confounded its description with
those of deep phlegmon and necrosis.

I heard, at the beginning of my studies, Professor Roux indicate
these deep abscesses about the long bones of the lower limb, and point
out the fact of their appearance, eBpecialty in young people, and the-
denudation of the bone which ensues. I have even heard him express
his regret at not having found in the authors any particular account
of these abscesses.

Bui it appears to me that attention was only called seriously to this
subject by two works of M. Chassaignao, one upon osteo-myelitis,'
the other upon acute subperiosteal abscesses,* In creating the word
osleo myelitk, and causing its adoption, M. Chaaaaignac described
lesions of the marrow of the bone wbich had been first published
Dr. Kaynaud in a remarkable work.* But while this latter authi
had spoken only of traumatic osteo-myelitis following amputalioi
the former pointed out spontaneous or primitive osteo-myelitis ani
its coincidence with deep abscesses external to the bone, and with lb©
disappearance or loosening of the periosteum.

Furthermore, M. Ohassaignac has the credit of having indicated the
frequency of these abscesses during early life, their development with
intense febrile symptoms, and the concomitant and consecutive
necrosis. He recognized that this affection has close relations with
osteo-myelitis, that the latter differs from it especially by its coinci-
dence with articular suppurations which do not accompany sub-
periosteal abscesses.

Still later, Klose' (of Hreslau) published, under the title Separaiiona
of the Epiphysis, a suppurative inflammation of the extremities of long,
bones which causes a separation between the epiphysis and the
diaphysis, and of which the anatomical and clinical description hna
much analogy with those of the osteomyelitis and acute subperiosteal
abscesses of M. Ohassaignac.

Then similar lesions were described under the name of juxta-

' }hyBary osleilia by Dr. Garnet, of Lyons, and under that of phleg-
periostitis by Dr. Louvet and M. Giraldtis.

'^>yJ

^F?

igntLB, OnzDtte M(ii1iaa1«, 18S4, p. SOS.

Li)(nao, AboiiH saus-pfirioatiquiia Algua. (MSuioiraade U Soaigt^ dBCUirargIa,, J
tonio IT. p. 281.)

• RuyiiBud, Sup I'luflamnittllon dn Tis.'iu m&iaURiiB 4m O* \ci\i'e^. ^^.TSsi^W
atnemWn da MMi-ciiie, IS31, tomn xsvi. p. 161,1
' Sloae, Arahirag OeaSralea da MfidHciiie, Aug. IS'jS. ,

I
I

48 SUBGICAL DISEASES OF YOUTH,

Beferring to ttese different deacriptiona and to the specimens which
T have jDat shown you, jou see that we might really employ any one
of these names. There is no doubt, for example, that we have here
M. Chassaignac's spontaneous osteo- myelitis, since the medullary
substance is inflamed and suppurating, as is likewise the neighbour-
ing articulation. In like manner the presence of a purulent collection
in the position which this author assigned to acute Bubperiosteal
abscesses would permit tis to choose this appellation, just aa the
presence of the same collection at the point of union between the
diaphyais and epiphysis, and for a certain distance alonj; the femur,
wonl^ justify ihe expressions "juxta-epiphysary osteitis" and "phleg-
monous periostitis." And, finally, do you not see that the eplphysary
cartilage is beginning to be destroyed, and that if this destruction
had continued the epiphysis would have separated from the diaphysia
and given us Klose's spontaneous separation of the epiphysis?

It seemed to me necessary to choose a name which should not
localize the inflammation so much as others have sought to do in such
or such part of the bone, which should indicate the origin of the
affection in the exaggeration of the nutritive process, at the junction of
the epiphysis and diaphyais, while the bone is lengthening, and which
should at the same time indicate the period of life at which this
exaggeration takes place. Therefore I used and continue to use the
expression acute epiphysary osteitis of youlh}

Look at these specimens.

Here is an osteitis which is general and complex, since it occupies
all the constituent portions of the bone, periosteum, bony tissue,
medullary substance; and there is no more reason for calling it
exclusively osteo-myelitis than periostitis or osteo-peri ostitis. It was
acute, for it ended promptly in suppuration. It is very intense in and
about the epiphysis; and, finally, it was developed in an adolescent.
If the affection appears in a child I will willingly call it acute
epiphysary osteitis of childhood, but it will remain none the less trae
that we shall be in the presence of lesions which are rarely seen in the
adult, and for the development of which the incompletion of the
ossification of the skeleton is the capital predisposing condition.

Now, to make the present case accord with those which you have
already met, and those which you muy hereafter meet, it is necessary
to add that this epiphysary osteitis of youth appears clinically under
several different forms.

First, there are the differences of location. The disease may develop
in the upper or in the lower limbs, but it is much more common in
the latter. You will find it especially at the lower portion of the
femur, and lower extremity of the tibia ; more rarely at the upper end
of this bone. In one case which I have published* the suppurating
osteitis appeared at the upper end of the femur, at the junction of its
neck with the shaft, and of the upper with tlie lower portion of the
great trochanter.

:G des Adoleseeim. (ArcUiveB G6u. ile M6d., 1S5B,

ACUTE EFIPHTSABY OSTEITIS. 49 .

Then there are vartetiea of intensity. I think I may aay that there
. eKists a subacute form without fever and with moderate pains, which
does not end in suppuration, hut nevertheless leaves behind it hyper-
ostosis and aometimea incomplete anchylosis. This form ia rare, I
cannot, at this moment, show you anv examples; hut I remember to
have seen, in 1864, at the H6pital de la Pitie, a boy 18 or 19 years
old, who had incomplete angular anchylosis o'f the left knee, with a
Bwelling of the lower portion of the femur, which, a few days before,
had again become painful after a fall. Thia patient told ua that he
had been taken, three years before, without appreciable cause, with
swelling and pains which had kept him in bed for two months; that
his physician had expected abscesses, hut that they had not formed,

■ and that he had been left wiih an enlarged femur, and unable to
extend hia knee completely. According to all the appearancea he
had had a subacute, non-suppurating epiphyaary osteitia.
The acute form advancing rapidly towards suppuration, like that
of the patient from whom these anatomical specimens come, is the
one you will most often see, and the principal characteristics of the
disease will then be that it is accompanied by intense fever, that it

I causes great pain, and that it occupies a sufficient length of the
affected bone to deserve the name of diffuse suppurating osteitis.
But this acute form itself presents three varieties which depend upon
'the location and the abundance of the suppuration.
In the first variety, of which the patient, deaerihed on page 38
'cffered an example, the suppurative inflammation appears to occupy
«nly the external face of the periosteum. The osteitis is none
■the leas complicated by it; but it is suppurative neither in the cora-
ipact tisaue nor in the mednllary substance, but only between the
'periosteum and the muscles. The abacesa heala without leaving
■either fistulte or necrosis; but hyperostosis results, thus demonstrating
■that the entire thickness of the hone has been aftected. It is in such
a case that I should consent to use the term phlegmonous periostitis;
and yet I should wish to add external, plegmonous, and suppurative
externa] periostitis. It is certainly the leaat dangerous of all the
suppurating varieties of epiphysary osteitis; hut it is also the rarest.
In the second variety, such as was seen in the tibia of the young

■ man of whom I have heretofore spoken (page 41), there was sup-
puration of the surface of the bone after destruction of the perios-
teum, and also in the peripheral or superficial layers of the epiphysary
cartilage. The compact tissue and the marrow^ — ^that is, all the rest
of the long bone — share in the phlegmasia; hut ihey do not suppu-
rate as the surface of the bone does ; nor, if the neighbonring articula-
tion takes part in the inflammation, does the arthritis become suppu-
rative, probably because the intensity of the disease is not sufficiently
great to propagate the suppurative form of the phlegmasia as far as
the synovial membrane. Thia is the variety which M. Chassaignac
described under the title of ocvie sub-periostenl abscesses. I should call
\X diffvae phlegmonous osteo periostitis. But I call your attention once
more to the fact that in these cases the disease is not limited to the
superficial part of tliq bpnp, jt occugifjg.iji^ wIioIq thickness; but the
J^^ 4 ^^^^^

SURGICAL DISEASES OP YOUTH.

IT
other parts do not suppurate; in them the osteitis rematna plas(
anri causes the hypertrophy of which I have so often spoken.
Finally, in the third variety, of which we have an example beFofl
us, all the constituent parts of the bone are not only affected, but
suppurate, and the suppurative inflammation is propagated, either
along the periosteum or along the parenchyma of the epiphysis, and
through the eroded diarthrodial cartilage to the neighbouring synovial
membrane. This is undeniably the most dangerous form, the one
which I call osteo-arthritis. It ends very often in death, or, if the
patient survives, in an interminable necrosis.

It remains now to decide whether the diagnosis between these dif-
ferent forms can be easily made. It is easy for the subucute form,
and for that one of the acute ones in which the outer surface of the
periosteum suppurates without destruction of the membrane, and with-
out deep suppuration of the bone. It can he established especially
by the aid of the general symptoms, which are moderate in these
cases, and by exploration of the cavity when the abscess has been
opened. If the periosteum has not been destroyed, there is no de-
nudation of the hone; if it has been, there is. The only real difficulty
I is to distinguish between superficial suppurating osteitis and general
suppurating osteitis; that is, at the same time superficial and deep, or
osteomyelitis. These two forms differ, perhaps, in the intensity of
the general symptoms, which is greater in the second than in the
first. But this difference is scarcely appreciable when you have only
one patient before you. In short, in both cases the fever and all the
resultant functional troubles are very marked, and the differences of
intensity are too slight to furnish a means of diagnosis. The pus has
no distinctive characteristics; the oily drops mentioned by if. Chaa-
saignac are found in both forms, as is easily understood, since these
drops come from the fat of the bone, and in both cases the pus is
supplied by the bone, of which both the outer and inner portions
contain this medullary fat, which exists as well in the external vas-
cular canaliculi as in the alveoli of the cancellous tissue, or in the
central medullary canal of the compact tissue. The diagnosis, and
especially the diagnosis which is important for the treatment, is com-
pletely established only by the presence of pus in the articulation, or
the appearance through the opening of the ab.scess of the bare dislo-
cated extremity of the diaphysis. When one or the other of these has
been discovered {and the former is the more common), there is no
doubt of the existence of deep complex osteitis, such as M. Chas-
saignac had in view in his description of osteo-myelitia.

The interest of this diagnosis is due to the following reasons: So
long as the suppuration is superficial, and the articulation is not
aflected, the preservation of the limb is the rule, and the surgical
treatment consists chiefly of free incisions, to open the purulent cavity
and allow it to be washed. It is true that death by purulent infec-
tion or hecticity may occur; but it is much less probable than when
the suppurating osteitis is deep, because, as I have often had occasion
to explain to you, pyaemia is chiefly due to suppuration of the mar-
■ in osCeo-m/elitj§.

TARSALGIA OF ADOLKSCKNXa.

The chances are, then, that the patient will get well when the di.
eaee is superQckl, It is true that tnis will only be after a lon)^-la!!tin|
necroais, which will generally end with adolescence. On the othi
hand, when there are at the same time suppurative arthritis, suppu-
rative oateo-myelitis, and ostao- periostitis, the chances of purulent
infection and hecticity are so great that amputation gives the patient
a belter chance to escape with his life.

LECTURE VIII.

TARSALGIA OF ADOLESCENTS.— (FIRST, SECOND, AND THIRD DEGRBBS.)!

^il

1st degree, (arsalgia wiUi ccintraction of the pernneal ninEi
rest, reHpjMBriug after nalking — Mulliod.i of exam i nation
rneut by real and the inimnrable apparatus. 2d degree, tarsalgia with c
tion wliioh dlanppears uiily l>7 thd aid oF anro^thexia, treated by straightening
Hie foot dnrlng anasathetio sleep. 3d degree, tarsalgia with retraotioii — Treated

t by SBOlion of the tendons of the lateral permiei— Ei.imination and disonsaion

I of the theories of MM. J. nafiriu, Bonnet (de Lyou), NSIaton, Dactienne (de

I Bonlogne) oonoerning paia/al volsus.

Gentlemen 1 We have before us two young men suffering from
that affection to which I have given the name tarsalgia of ailoleacenls,

T. The first has been in the wards for more than two months, and
rill soon leave us. Let me describe briefly his condition at the time
if admission.

He is 17J years old. Two months before his admission into the

ispital he felt pains in his left foot. When questioned as to their
probable cause, he replied that he knew of none. He had never had
rheumatism; he had not sprained his foot; he enjoys general good
}iealth, and nothing about him indicates a scrofulous constitution. Wa
learned only that he had grown rapidly during the last year, that six
months ago he commenced work as a grocer's boy, and that this work
compelled him to remain on his feet all day, and to take long walks.
At first the pain was slight, it began at the end of the day, disappeared
doring the night, and did not reappear at all during the morning;
then about three weeks later the pain became sharper, was accom-
panied during the day by a slight swelling, and became at times severe
enough to force him to rest for half an hour or an hour, after which
he was again able to walk and attend to his work. Then for about a
fortnight before admission the pain during the afternoon was so severe
that he limped, and was obliged to rest, and even to lie down two or
rhree limes toward the end of the day.

The day ha presented himself at our consultation^ L cftWeA "jwfix
intion to tbe fact that hia foot was tuTnei QV)L\.'ww^"vii.''lQft V^'^'^^^

SURGICAL DISEASES OF TOUT.

I
I

hich characterizes that vice of conformation k
that it was kept in this position by persistent
tensors and lateral peronei.

The next moroinj:;, after he had been in bed for oearly twenty-four
hours, we no longer found the valf^ua and contraction observed the
day before ; the foot possessed all its movements, those of laterality,
as well as those of flexion and extension.

Questioning him about the pain, he replied that, for the moment,
did not suffer at all. Still, by pressing with one finger on the oui
side of the foot a little in front of the external malleolus, in a rather
eircumscribed point corresponding to the junction of the calcaneum
with the cuboid, I awakened some pain. Pressure on the inner side,
a little behind ihe tub<jrcle of the scaphoid, caused a similar pain, and
the patient told us that those were the points where he suffered aft
standing aud walking all day.

You then saw me extend forcibly the great toe with one hand, pla{
the thumb of the other against the under portion of the head of
first metatarsal bone, and ask the patient to press back my thuml
He did it as easily as with the other foot, which showed that the pero4<
neus longos, which, ua you know, is designed to form and maintain
the arch of the foot, was at that moment neither paralyzed nor inert.
It was evident thai to understand the affection thoroughly we should
have to examine the patient again after he had walked for an hour or
two ; so I told him to get up the next morning at six o'clock and walk
about the wards until the hour of my arrival (eight o'clock).

When we came to his bed the next day, you saw that the left foot
had again taken the position of valgus, which we noticed the first
day at the consultation, that is to say, the outer border of the foot
was raised and the toea slightly turned outwards, aiid on the inner
side the head of the astragalus was notably more prominent under the
akin, and hence apparently larger, than on the other foot. But thit
was only an appearaiioe, for the day before, wiieii the foot
natural position, there was no difference in size between the two, Ws
could also see nnder the akin the tendons of the extensor longus, eX'
tensor proprius poUicis, and tibiulis anticus; and we could both see
and feel above the external malteolos the rigid prominence of the con-
tracted peronei. Finally, we could feel iuid follow with the

, along the outer aide of the foot the prominent cord formed by th(
tendon of the peroneus brevis. When asked to let his foot go, to rela:
the contracted muscles, the patient was entirely unable, in spite of h^

I good will, to meet our wishes. Grasping the leg Brmiy with both

I hands above the ankle, and raising it from the bed, I shook it sharply
from side to side, but was not able to give any lateral movement to
the foot, while by the same manoauvre on the right aide I produced
marked lateral movement. Then fixing with one liand the lower part
of the left leg, and grasping the sole of the foot iv ith the other, I tried
in vain to turn the latter outwards or inwards. All my eft'orts were

' transmitted to the leg, and the foot executed no lateral movement, that
IB, none of those whicii take place in the medio-tarsal aud ualcaueoil
astragah'aa articulations.

t^^l

ae
n-

TARSALGIA OF ADOLKSOKNTB. 68*

. On the other hand, T could easily give the foot the movementa
rflexion and extension, those which take place chiefly in the libio-tarsi
articulation.

Examining then the sole of the foot, I found exactly the same arch as
on the other aide, so that if I had wished to use the name so often em-
ployed by our predecessors, I should have had to say " painful arched
Lvalgus," Furthermore the skin behind the inferior projection of the.
ITieadaof the metatarsal bones presented the normal folds which go withi
Bthe existence and proper conformation of the plantar arch.

Of what disease were these the symptoms? Of a singular diaeas
■iJie nature and anatomical lesions of which are still imperfectly knoivn,
l.and which has three dominant clinical characteristics : pain, pmvoki
sepecially by prolonged walking; outward deviation of the foot,
valgus; and prolonged contraction or contracture of the anterior s
exterior muscles of the leg, or, if you prefer, of all the muscles su|
plied by the peroneal nerve. It is evident that in this case the \
was not congenital, that it was accidental, and even temporary,
it disappeared completely after rest.

The question then to be answered was this : was the pain caused bj
I and closely connected with the contraction, or was the contraction onlj^J
Lthe consequence of the pain which was itself the primitive phi
Inon?

* To answer this question in the case of our patient, I turned to hii
clinical examination, and to the remembrance of a similar
which I was enabled to make an anatomical examination.

In our clinical investigation I called your attention to two thin^
first, according to the commemoratives pain was the initial symptom,
not only of the disease, but of all the attacks which occurred at the
end of the day. During two or three weeks the young man eu&ered
without noticing any deviation of the foot; the latter only appeared

t later, and, in every painful attack of an evening, the valgus appeared
only some time after the pain. Moreover, the first day, when, after
twenty-four hours' rest, the muscles were relaxed and the valgus had
disappeared, pressure caused pain, not along the coarse of the muscles
of which I have spoken, but over the posterior bones and articulations
of the tarsus. For me then in this case there is no doubt, the pain
was primordial, was increased by walking, and caused, by reflex action,
the muscular contraction and deviation of the foot outwards.
But then what was the origin and seat of this pain?
Here, I invoke the result furnished by pressure with my fingers.
' The pain which that caused could have no other origin than the bones
pOr tbe articulations.

ButI prefer to refer to the case, unique, I think, in science,' in which

s enabled to make an autopsy.
It wad a young girl, IS years old, who presented the same symp-

■ I ehoald add that M. Lernux, o[ Veraaillxa, Qommuiiioiitrd to tlitt SouifiU dtt CliE-
■inirgie (,G<it. de> llopilaux, 1805) a case iu it hirh dissoution ot tlie foot showml aitiO'
Ci^ar lasions similar to tbosa nhich 1 aovr mention. These legions beluuged to ft
K«lee uf larsalgia of adolununuta. But thu font iras tamed iunardH, iu varus, iu£tiiA.>l
Bof^beiu^ iu Yiilaua, a^ it was iu all thn oftsei wUioh V \i.a,^ttQ\it.Bif eA,

r64 SDKGICAL DISEASES OF YOL'TH.

toms as this young man does, and who died suddenly of cholera a
days after admiaaion to the Hopital de la Pitid The anatomical e!
amination, the details of which I communicnted to the Acad^mie c
Mddecine,' showed na that the as tragalo- scaphoid and calcaneo-cuboid
articulations were affected with dry synovitis, that in several points

»the diarthrodial cartilages were destroyed by a process of erosion or
ulceration, and that below theae points the corresponding cancellous
tissue was red and infiltrated with blood as in osteitis of the first
degree. These lesions, similar in several respects to those of chronic
dry arthritis, and to the principal of which Brodie gave the name of
ulceration of the carlihges, left me no doubt of their connection with
the clinical symptoms in this young gii'l. The ulceration mentioned,

I the subjacent partial osteitis, and the dry synovitis had become pain-
ful during exercise, and tbe pain had brought about contraction of
the muscles and valgus.
In my opinion, the same things have occurred in this young man,
and in the three or four other examples which we see every year "
these wards of different degrees of the same disease.
Let us now see, gentlemen, what there is that is strange or unco'
mon about tliia affection, and iiow far we can explain it.

The first thing that strikes us is that we are in presence of a variety
of articular disease, chronic dry arthritis, which is found in the other
^^ articulations only at tbe end of adult life and the beginning of old
^L age, and in these the tarsal articulalion appears to be confined esclu-
^H sively to adolescence. For it is found in subjects who, while they are
^V growing rapidly, are exposed to fatiguing toil, and compelled to take
long walks, olieri with the addition of a more or less heavy burden.

What connection is there between the growth of the skeleton and
this arthritis, or rather arthro-osteitis with ulceration of the cartilages?
I cannot say. To explain the osteitis of adolescents, I referred to thi
exaggeration of nutritive work going on about the epiphyses. Bi
here in the astragalus there is no epiphysis, and the one on the p<
terior portion of the calcaneum is far from tbe articular surface i
which the lesions appear ; in ray autopsy it was already united, ai
no lesion existed in it. We must then admit that completion of growth
predisposes, without accompanying union of the epiphyses, to the

I lesion which now occupies our attention, and I invoke the process of
growth because this is another of the diseases of youth. I do not
deuy its existence in children, although I have never seen an ex-
ample, but you will not meet with it in the adult. You will see adults
affected with irremediable valgus, but they will teil you their deforai''
jty began at the age of 16, 17, or 18 years.
But is the contraction of the muscles equally uncommon? Ni_
and yes. I say no, for the clinic often shows us spasmodic eontrae'
lions in connection with articular lesions. Think of coxalgia, at the
beginning of which you find the joint 6xed, often in extension, some-
times in very marked flexion, by all the peri-articular muscles, and
especially by the psoas. Then remember the arthrites of the ki

esf
ina

.ts

TARSALGIA OF ADOLKSGENTa.

iriili permanent flexion due to contraction of the biceps, semi tendtj

nrwus, and semi-membranosuB. Finally, does not temporary torticolliju

Fiwhicli is also a disease of childhood and adolescence, appear in rnanW

I caset) to be caused by a contraction due to rheumatic arthritis of thflj

[cervical articulations?

But let us remain in the region of the foot. I have sometimes seen J
in adults, and I have shown in myelinic two patients who, whilst suf-
fering from gonorrhceal tibiotarsal arthritis, had a deviation of the
foot inwards, which was clearly due to contracture of the tibialis pos-
ticus. These were not the muscles of which we are speaking to-day,
but the contractures were dne to aa articular affection.

That which is unusual and very difficult to explain, is the constancy
of the contracture of the anterior and outer muscles in adolescents
affected with tarsal osteoarthritis. This constancy is such that T can
understand perfectly how eminent cliniciats should have considered
the disease aa located in the muscles. When MM. Jules Gufirin and
Am&I^ Bonnet' (de Lyon) described painful splay-footed valgus, and
advised aa principal treatment tenotomy of the lateral peronei, it is
incontestable that they believed in a deformity produced by cootrac-
^_.tion, and then retraction of these muscles.

^^k "When N<31aton compared this disease to writers' cramp, he thought
^^Eit was a contraction, becoming painful, of the peronei and the exten-
^^Uora, just as in writers' cramp there is painful contraction of the flexors
^KfUid extensors of the thumb.

^^L* This same idea of a lesion primarily muscular, led M. Duchenne
^V](de Boulogne) to an analogous theory, according to which the origin
^^'of that variety of valgus in which the foot remains arched is an ex-
aggerated contraction or contracture of the peroneus longus. Beyond
the fact that it is impossible to prove this theory, it has the inconve-
nience of taking into account neither the initial pain, which is much
more marked over the tarsal bones than along the course of that
muscle, nor the articular lesions which I pointed out, nor the ten-
dency to anchylosis which is one of the possible terminations of the
affection. It offers also this singular contradiction that, according to
it, as I shall soon tell you when speaking about another patient, on-
tractiou of the peroneus longus would give, with the exception of the

P hollow instep, exactly the same physical and functional symptoms as
would incomplete paralysis of the same muscle, which latter, accord-
ing to M. Duchenne, would produce the flat-footed valgus.
Furthermore, it was because in my opinion there were, together
with an origin in the skeleton, consecutive effects, singular and im-

fortant lesions of the muscles, in this strange disease of youth, that
proposed for it, in 1865, the name, which prejudges nothing of this
nature, of larsal-jia of adolescents.

I add that in this patient we have to deal with what I have called
the first degree of tarsalgia, that in which the pain, and especially the
contracture and the valgus disappear after a few hours' re.st, to reap-
I jjear when walking has been renewed and kept up for a certain lime.

1 Bounet, Tli6rapBHtiqua das Malaiie* M\,\ii'a\B,\te*,^M\%,'VWA.

"60 SURGICAL DISEASES OF YOUTH.

What would have become oF it if we had done nothinf^ ?

Perhaps a cure would have taken place spontaneously: but

doubtless would have been only iti case the young man had given up
" r a time the fatiguing occupations which had been the occaaional
cause of his trouble.

T have met several patients who, from the information furnished by
them, appeared to me to have had tarsalgia of the first degree, and to
have been cured without surgical treatment by refraining from long
walks, I treated in my private practice a young girl, sixteen years
old, who had been affected with valgus for a week, after having felt

Eain for a fortnight when walking. She was relieved by keeping the
ed for a week, and by avoiding for some time thereafter prolonged
Blandiug and walking.

But as, in our young man, the tarsalgia was very marked, and had
already lasted several weeks, and as the nece-fsity of working for his
living would have led him to endure the pain after obtaining a alight
diminution by temporary rest, I had every reason to suppose that the
tarsalgia would have passed first to the second degree, that in which
the contracture and valgus no longer disappear by rest, but only
during anteathetic sleep ; then to the third, that in which the muscles
D longer relax, even during sleep, and may be considered as having
passed to the condition of permanent shortening, which yon know
by the name of retraction ; perhaps finally to the fourth, that in which
the medio-tarsal articulations, or at least one of them, and especially
the astragalo- scaphoid, are anchyloaed by fusion. For one of the
conaequenees of the slight arthritis, of which you have seen the first
degree in this patient, is the formation of one or more anchyloses.
A few years ago I showed, at the H6pital de la Piti^, a man fifty years
old, io whose left foot there was, together with an old valgus, a union
of the astragalus and calcaneum; and he told us that at the age of
eighteen he had had a sprain, which he did not think it necessary to
have treated by a surgeon, and in consequence of which this deformity
was produced. I should add that this anchylosis, after having trou-
bled him for a long time, and having rendered long walks impossible,
had ended by becoming indolent, and causing no further fonctiooal
trouble.

You see, gentlemen, that in speaking to you of the course of this
affection when abandoned to itself, T made no mention of suppura-
tion. I should fear it, perhaps, if I had found at some points of the
tarsal region adiffused swelling and doughiness with semi-fluctuation,
such as we find in fungous synovitis or white swelling. Not only
were these signs absent, but moreover the existence of valgus and
contracture led us to dismiss the idea of an articular affection which
might terminate some day in suppuration. B'or it is a remarkable
fact, and one abundantly proven by clinical observation, that arthritis
tending to suppuration is not accompanied by these symptoms (con-
tracture and valgus), and when we see these latter appear, especially
in a patient who shows no signs of scrofula, we know that the affec-
e/an will end neither in articular suppuration nor in caries.
In this respect the prognosia was favourable-, \iMl.'A\ift4.\.\i\a\.'QnoQ-

th^l

TARSALGIA OF ADOLESCENTS.

venience, in case the disease had been abandoned to itself, it woali
undoubtedly have lasted several years, during which the young mai
would have been constantly disturbed in his occupationp, and it might
perhaps have ended in definitive retraction and anchylosis, which are
always the cause of great trouble in walking until adult life has fairly

t begun.
TVeatment. — It results from all that I have toM yon, that the ehirfj
indication in this case was to keep the foot motionless. In that wa;^
we eould cause the pain to disappear, and with it the muscular cort-
tractnre which was its reflex efteet. It was also the means by which
to obtain the cure of the articular lesions, the existence of which we
had the right to assume ; notably that of the osteitis and the ulcera-
tion of the cartilages. I am unable to tell you if this ulceration is
capable of cicatrizing purely and simply, without restoration of the
cartilage; or if the latter can be reproduced, which does not seem to
me impossible at this early period of life. But I have had no

I anatomical demonstration on these points. I only know, from th(
resLilta which 1 have obtained ia a dozen patients whom I hav(
been able to follow, that all the clinical phenomena of tarsalgia
the first degree may disappear after a rest of two or three months,
I therefore applied an immovable apparatus whilst the muscles
were well relaxed. While the foot was kept turned inwards, I
wrapped about it a thick layer of cotton hatting, which I carried
nearly halfway up the leg; over this I rolled tightly a dry bandage,
then another soaked in plaster mixed with a solution of one part of

felatine in a thousand parts of hot water. The plaster dried in a few
ours. The patient remaijied in bed for six weeks without having
the bandage removed; at the end of this time T let him sit up, and a
fortnight later — that is, at the end of two months — I removed the
bandage, and let him walk as much as he chose.

To-day, a week later, all appears to be in good condition. NOi
pain, no contraction has reappeared. I hope the young mnn ia curedJ
and I shall let him leave the hospital in a few days. I shall advise

»liim to wear an elastic stocking and snugly-fitting shoes, so as not to
'turn or sprain the foot, and thus bring back the tarsalgia; also to
■Oome and see us from time to time; and if I notice that his foot has
any tendency to turn outwards again, T shall make him wear a laced
shoe, the sole of which will be nearly half an inch thicker on
inner than on the outer side, so that he will have to walk with
foot turned inwards.

Unfortunately, I am not certain that the cure is final and definitivi
I have seen, in several patients who had been treated in this way, th
pains, contractions, and valgus reappear a few weeks after they haS'''
again begun to walk, so that it was necessary to repeat the treatment.
The reason doubtless was that the articular lesions were not completely
healed; for you understand that in certain cases the ulceration of the
cartilage is not cicatrized or repaired in two months, and it is to be
regretted that there is no sign hy which we can determine the per-
sistency of the lesion after it has been sufBcientlY d\«\\B.\9>W'J>. Vi-^
treatment to no longer occasion t'unctionaV fi\ftOT(\e^,\]Vi>i te,^-^^«»xwiKR'
^^ofwbicb ia nfterwards caused by walkrag aaA aVo.uiiA'ci^. ^^^^^H

lad^B

las

led ^^

la^H

nt ^^

68 SURGICAL DISEASES OF YOUTH.

II. The other pntient whom T mentioinjd at the beginning is
eighteen years old. He thinks he sprained his left foot three monlhe
ago; be suffered but little from it, and kept at his work as house
servant, reninining on his feet most of the day. For a few weeks he
had moderate pains, whioh, like those of the preceding patient, were
notably greater at night. Then he noticed that his foot turned out-
wards when he suffered most. This deviation disappeared by rest;
but a fortnight ago it ceased to disappear, the pain became greater,
and a week later the patient was obliged to enter the hospital.

The first and second days, after twenty-four and forty-eight hours'
rest, we found that the left foot was flat, almost without any plantar
arch. Hut this confurmatioo is not eoncected with the present affec-
tion ; it is old, perhnps congenital, although the young man cannot
give lis any cniegorical information on this point. In any ease, it is
lis marked upon the right foot, which is the seat of no disorder, as it
is upon the left,, which has been lame for some time. Further, we
find the same physical and functional symptoms as in the preceding
patient; that is, deviation of the toot outwards, apparent enlargement
of the astragalus, suppression of the lateral movements of the foot,
pain upon pressure on the outer side over the ealcaneO'Cuboid articu-
lation, and prominence of tlie tendons of the extensors and lateral
peronei.

It was necessary to know if the shortening of the muscles, which
was betrayed by the prominence of the tendons and the deviation
outwards of the foot, was definitive and irremediable, or if it could
disappear and be replaced by relaxation. You saw that the shorten-
ing persisted in spite of the repose. In oj-der to ascertain if it could
cease, I subjected the young man to the influence of chloroform, and
after he had become well anaesthetized you saw that all the muscles
were relaxed, and that I profited by it to turn the foot inwards, and
tix it with a plaster apparatus.

In this case then, as in the preceding one, we had to deal with tar-
salgia of adolescents, but it was tarsalgia with splay-footed instead of
arched valgus. The succession of the phenomena- — ^firat, pain without
contracture, then pain with temporary contracture, finally pain with
prolonged contracture and valgus without intermittence — authorized
me to believe that this was again a disease, the origin of which was
in a lesion of the tarsal articulations, but in which the contracture,
a secondary reflex effect, was liable to become of chief importance,
because prolonged contracture migbt become retraction, tiiat is, the
muscles would be unable to relax, and as this retraction would he
inevitably accompanied by immobility of the joints, the latter would
be so much the more disposed to anchylosis. If I have obtained by
means of the aoEer^thesia a permanent relaxation, if, the articular
lesions disappearing under the influence of rest, the pains are not
reproduced and no longer cause reflex muscular contraction, the
arlicuiationa will be able to renew their functions, and the foot to re-
establish itself in a normal condition. It was with this hope that I
applied [he plaster apparatus upon the foot placed in varus after
auwatbeaiA.

TARSALGIA OF AD0LE9CKNTS.

59 J

I must now ask again if the explanation wtich I repeated here o(^
the lesion which now occupies us is a sound one, and if we oiight^
not to invoke the theory of M. Ducheiine (ile Boulogne). This J
theory is as follows : Spluy-footed valgus presuinea insufficient ]
action on the part of the peroneua longus, since the action of this i
muscle, by its simjile tonicity, is to maintain the hollow of the instepJ
by drawing the first metatarsal bone downwards and outwards. Thafl
origin of the affection might then be in this muscle, which would]
contract too feebly, or, as tlie author says, might be the seat o
impotence. In consequence of tins impotence the foot would flatten ;■
the plantar nerves, having become painful by the increased pressure.
would provoke by reflex action a painful contraction of the peronei I
and extensors ; perhaps, even, the flattening of the foot might subject |
certain points of the articular cartilages to an unaccustomed pres-
sure which would cause their ulceration.

I ouglil to say, however, that M. Duchenne, in his last article upon j
this subject,' does not say much about the articular lesions, or the'fl
origin of the pains. I do not clearly understand whether, in his \
opinion, these latter have their origin or their principal seat ia the f
impotent musl^le, in the muscles contracted consecutively, or in the ]
nerves, or even in the bones and the articulations.

This is, furthermore, the objection which I address to all tliose who
attribute valgus to a functional lesion of the muscles. Why this
radiating pain? Why, above al!, this pain on pressure when the
muscles are relaxed and the patient at rest; this pain which, more-
over, in most eases, is the initial phenornenon and precedes contrac-
tion for quite a long timei'

la tlie present case I cannot admit the impotence, always very
probletnatical, of whichM. Duchenne speaks. My chief reasons are
that the flat-foot far antedates the pain, and that it exists upon the
right side where there is no pain, as well as upon the affected left
' side ; that the pain, as I have just said, was the initial phenomenou,
and that finally before using aniesthesia we found the peronens
longus contracted as wel! as the pertmeiis brevis. Perhaps they will
claim that this muscle, at first impotent, became afterwards con-
tracted. I will grant it if they wish; but I ask how then will they
prove this impotence to have been the cause of the trouble? Sup-
poee the theory correct, it cannot be danionstrated by clinical study
in cases like this one, where the foot was flat long before the appear-
ance of painful symptoms.

1 recognize, loo, that M. Duchenne rests his theory of impotence
upon a powerful argument; the cure of certain patients affected with
splay-footed valgus by faradization of the jjcruneus longus. But
this argument should not have loo much weight. Whatever we may
think of the theory, there will always be a singular functional lesion
of the muscles in tarsalgia, and I understand how the passage of

la Crnmpe dii Pied,

I'lmpntenoe fun a UoD lie lie dn long
lueiie ae ee MuHule. Uuiou M^diuale, tomn
I) Iw notiupd thai tlia taae ot '^^Vi^-ltioV. i«^Vwii.\^ "^iw
forij yearn olfl, au4 nol ol

I 60 BUEGICAL DISEASES OF YOUTH.

eledtrio currents might advantageously modify this lesion and the
trouble of innervaLion which causes it.

I do not accept then the theory of impotence, because dinical
and anatomical study of the disease does not confirm it. But if
necessary, I shall make use of the therapeutical resource offered ua
by M. i)uchenne. If, after two months of immobility in a good
posture, the pain and contraction return, I shall try electrization of
the peronei and the anterior muscles of the leg. You may have
seen last year a youth afi'etted with fiat-fuoted tarsalgia, who im-
proved and seemed to be cored by twenty applications of electrioity;
but I still think, that, by reason of the presumed beginning of the
" tease with articular lesions, we shall do well to first combat these

lions by immobility, and to address ourselves to the muscular
element only when it shall have taken a marked predominance, and
an importance which it had not at the beginning.

III. Tarsalgia of the bd degree with retraction of the lateral
peronei; treatment by tenotomy.

Here is a new case of tarsalgia in a subject 19 years old. The foot
is arched and in. valgus. The extensor muscles relax by rest, but it
is not the same with the lateral peronei ; they remain tense and promi-
nent under the skin. I anaesthetized the patient, but did not get them
to relax. I am then justified in thinking that these muscles are defini-
tively shortened by the production, consecutive to prolonged contrac-
tion, of the condition which we call retraction. The go rn memo rati ves
are also favourable to the opinion that there was first pain in the articu-
lations and bones, and that the contracture occurred afterwards. Now
that the retraction exists, the muscular lesion has become the most
important. For, even if the articular lesions should diminish, the foot
would Btil] remain deviated outwards, a condition which would make
walking difficult and at times painful. I know that after a time this
difficulty and this pain would cease, but still they would exist for a
certain number of years. Moreover, instead of diminishing, the
articular lesions might extend and terminate in the anchylosis char-
acteristic of the 4th degree of tarsalgia, anchylosis which would still
cause functional disorders for a certain number of years.

It is in cases of this kind that tenotomy of the lateral peronei ia
indicated. I consider it useless when the contracture can be overcome
by rest or aniesthesia.

You saw me perform it yesterday on this patient. It consisted of
a first time, in which I made a fold in the skin, and pricked its base
with a pointed tenotome three finger- breadths above the external
malleolus. In a second time I introduced through this opening,
between the skin and the posterior face of the tendons, the blade of a
pointed tenotome lying on the fiat. I then turned the blade towards
the tendons and divided them, one after the other. I was at once able
to turn the foot inwards and fix it there with a simple roller bandage,
and iu four or five days, when the slight cut in the skin is healed, and
we are sure there will be no suppuration, I shall apply a plaster appa-
ratus to fix the foot and keep it slightly turned inwards. I have
already perforaitid this operalioa twite for tacaalgia of the 3d degree

TARSALGIA OF ADOLESCENTS. 61

(with retraction of the peronei). The patients met with no accidents,
and left the hospital apparently cured. As they have not come back
to me, I have reason to hope that the cure has been maintained.

If from the results of clinical investigation we had reason to think
that the peroneus longus did not share in the retraction, and that the
peroneus brevis alone was aflFected, we might spare the first, and divide
the second only on the dorsal surface of the foot. I know that M.
Duchenne (de Boulogne) has recommended this modification for those
cases which he attributes to the impotence of the peroneus longus.
Thus far I have met with no cases of this kind. If I should meet with
any I should not hesitate to divide the peroneus brevis alone.

PART 11.

FRACTURES OP THE LIME

LECTURE IX.

^CHaaity of fitndying ooaBolidation ii
§ 1. CoDSoliilalion of the shaft of 1
are end lo end — whsa tliey hsTB ot
pig — Repair

long bones, flat bonea, and aliort bones.
ig bones: — lat period, when tlie fragments
rridden — Study of the prooeea in a ji"infa-
period, ID 090 It la-peri osteal capiinlt<-

e tranBrormatiana into flbroue and fibra-cRrtilajfinoas aiibstanue— Ifew dif-
ferences accnrdiag^ as the fragincnta are end to end or overridden ; 3d period,
coupietinn of OBsification — Interpretation of tbe proWsional cailns and tbe defi-
nitive callus ; 4th period, obliteration of veius^Synovitis of neif^hbonring ten
done and artioalatious — Musonlar atrophy. § 2. Conaolidatlon of the ex tre mi ties
of long bonea. § 3. CnnsoUdatiou in flat bones and abort bonea.

Gentlemen : You will find in your books rather lengtby deacrip-
tiona of the consolidation of fractures, descriptions in which mention
ia made of experiments upon animals, and of the authors of these ex-
periments. It is undeniable that this subject ia one of those in which
experimentation has been most useful, for it is seldom that we have
occasion to study upon man the anatomical character of consolidation,
death happeniug very rarely during its course. But there are some
parts of the skeleton upon which experiments are difficult to make,
and, in consequence, have not been made; these are the spongy ends
of the long bones and the spongy short and flat ones. In the first
two the force cannot be concentrated with sufficient exactitude upon
the parts which we wish to study to produce the fracture at the desired
point ; in the last we are liable to injure at the same time the organs
contained in the cavity which the fiat bone contributes to form, and
to cause death before the time necessary for the study of the consoli-
dation has elapsed. The result is, that fracture of the shaft of long
bones has been well studied, for these experiments are easily made,
and that tbe ideas thus acquired have been a little too freely applied
to fracture of the extremities of these bones, and to the short and flat
ones.

It is true that in his thesis, so justly esteemed, Dr. Lambron' has
indicated perfectly the differences presented in the formation of the

' LambrOD, Th«MB &e ¥»\ft,l%^.

CONSOLIDATION AFTER FRACTURE.

jallua at different points of the akeletnn. But na this distinction is-
made only at the end of his work, and after a great display of erudi-
tion which calls attention only to the authors of experiments upon
the diaphysea, and as it is not made sufficiently prominent, I think
perhaps, proper attention has not been paid to it. It therefore seems
to me indispensable, in order to leave no false ideas in your minds
upon this subject, to describe separately consolidation in the shaft of
long bones, in their extremities, in the short bones, and in the flat
ones.

L § 1. Consolidation in the Shaft of Long Bones.

^ I show you here twelve femurs of guinea-pigs, the shafts of which

^ present different periods of consolidation after fracture. The shortest

of these periods is forty-eight hours, the longest ninety days. I do

not claim to apply to man all the results which we find here. I wish

you to remark especially that in these animals the work of consolida-

lltion advances more rapidly than it does in our femurs, and in most

■of the bones in the human race. For, besides the varieties in the

raptitude of each kind of animal, there is a rapidity which depends

upon the size of the bones. The smaller they are, the more rapidly do

they consolidate, and as the bones of guinea-pigs are much smaller than

those of men, this is the principal reason why the fractures which T

now show you have advanced so much more rapidly towards a cure.

Leaving this rapidity out of account, we find the work of repair
is accomplished in these animalts, as in us, in three periods, of which
you here see specimens sufficiently well marked.

Isl period. — Clinically, we have a first period which I seldom fall to
point out to you in fractures of the large long bones. It ia charac-
terized by three principal symptoms : ecchymosis, and its progressive
extension to a certain distance from the fracture; swelling of the
limb; spontaneous pain, and especially pain increased by pressure
and motion. The first of these symptoms is sometimes absent, the
other two almost never. We call this first period mfiammatory, be-
fceanse the swelling and the pain, accompanied sometimes by a little
idness and heal, the febrile movement which is added in certain
I, can hardly be explained otherwise than by an inflammation.
Chis period lasts, in the human race, fur from six to fifteen days,
If less, according to the size of the bone, the degree of the con-
and the idiosyncrasies.
In ihe guinea-pig this period is shorter, but the anatomical and
fchysiological phenomena which occur during it are the same as in
They differ a little if the fragments are end to end or if they
overridden.
There is one point, however, which is common to all cases, and
which we find in these specimens of recent fracture: it ia the effusion
of blood between the fragments, in the thickness of the periosteum,
between the periosteum and the bone, in the medullary canal, and in
the muscular interstices, to a certain distance above and below the
solution of continuity. In ihe most recent fracture of these tou.v.,^^'*.
i^ood is the most abundant, most cuagu\&le&, e.'o.^ '^m.^i^V \^ '^^^

1
I

■

I
I

«4

FRACTUHE3 OF THE LIMBS.

oldest., a week, the blood is less abondaiiC, leaa coaguliited, and more
liquid. Why this last circumstance? Is it because the solid part of
the Hood, the corpuscles and the fibrine, have been in part absorbed,
and the serum has remained? Bat this is not what usually happens.
The serum is the first to he absorbed, and there remains n thick paste
formed by the clots. When, instead of a paste, the collection be-
comes more liquid, as is sometimes seen in subcutaneous effusions of
blood, we attribute it to the effusion of a new liquid, the serosiiy,
into the collection, and its mixture with the blood. Is it not probable
that the same thing has taken place here, and that the blood has be-
come a little more fluid by the addition of a certain quantity of
serosity ? And, as this has occurred under the influence of the
inflammatory process, we may consider it as the plastic or coagulable
lymph pointed out by Hunter, as the blastema of contemporary
histologists, that is to say, as a product analogous to that which is
furnished by all solutions of continuity, and which is capable of
undergoing the transformations necessary to ultimately reconstitute
the divided tissues. In this serosity you find also the substance
which the ancient authors, and, in the eighteenth century, Haller
called the bony or glutinous juice poured out at the beginning of
conaolidation.

The efl'usion and infiltration of blood are about the only lesions
which I shall show you in the most recent fractures, those of the
second, fhird, and fourth days.

I. But here is one a week old, in which the fragments are nearly
end to end. There ia still some of the aero-sanguinolent liquid, bat
you see that continuity ia re-established on the outside of the bone
by a quite thick, fibrous-looking substance, forming about the frag-
ments a easing or capsule, which ia not sufficiently stiff to prevent their
moving upon one another. By its outer surface, this capsule is in
relation with, and even very closely adherent to, the deep muscular
layer, and is continuous above and below with the periosteum. Its
inner surface looks towards the fragments, and is in contact with the
sero-sanguinolent and glutinous liquid interposed between them. In
this capsule you find what Duhamel, Dupuytren, Brescliet, and
Villenn^, described under the name virok externe. external ferrule.
What la this ferrule ? How, and by what has it been formed ? If
we were sure that the periosteum had not been torn when I broke
the bone, we should say that it had been formed by this membrane
which had become inflamed and thickened in consequence of the
accident. But as I took care, after haying made the fracture, to press
the fragments several times outwards and inwards, I presume that
the periosteum was torn, if not all around the bone, at least over a
great portion of its circumference. If, then, we find to-day the con-
tinuity re-established, it is because repair or cicatrization has taken
place by the thickening and rapid transformation into connective
tissue of the plastic lymph exuded and mixed with blood, of which
I have just spoken. That does not prevent the periosteum from
being thickened above and below the solution of continuity. But I
waatfou to notiae that in addition to ihia thinkening, there baa been

CONaOLIDATION AFTER FRACTURE.

formation of a new periosteam all along the aolution of continuity
of the primitive periosteum; ami it is probable that the materials
for this re|*air have been supplied not only by the periosteum itself,
but also by the muncular layer which h;i3 participate'!, more or less,
in the solution of continuity, anil which, at all events, participates in
ihe consecutive phlegmasia. You will thus appreciate what there
was of truth and what of cxagi^eration in the celebrated opinion of
Duhamel, an opinion shared hy many experimenters, and notably by
Dupuytren, Breschet and Villerm^, Flourens, Lebert, that the peri-
phery of the callus, what they called the external ferrule, was formed
by the thickened periosteum. This is true for the portions of thia
membrane which lie above and below the solution of continuity, but
at this latter point the capsular ferrule is completed by a tissue of
new formation which is a periosteum, if you choose, but a new or
cicatricial periosteum which is the result of a prompt transformation
of the lymph or blastema exuded after the accident. There was
evidently exaggeration on the part of Duhamel and hia auccessora,
when they attributed the whole ferrule to a thickening of the normal
and primitive periosteum.

As for the marrow and the space between the fragments, you sea
there nothing more than the infiltration of blood, and thus you deter-
mine a firet period characterized at once by effusion of blood, effusion
of lymph, repair by means of the latter of the periosteum, and its
thickening, which seems to me to be undeniable, and as to the ex-
istence of which, I am surprised to see doubts expressed in some
works, particulnrly in that of Billroth.

II. Here now are two guinea-pig femurs broken eight and nine
days ago, in which the fragments, instead of remaining end to end,
have overlapped. You still find liquid blood at the extremity of the
fragments and between the surfaces where they correspond to one
another. But you notice that the periosteal casing is not so complete
aa before. It is interrupted at two points, those which correspond to
the greatest prominence of the overlapping fragments, and its con-
tinuity exists only over part of the circumference of the fracture.
The repair of the periosteum has been incomplete. It is lacking at
those points where the separation between the edges of this torn mem-
brane was too great, or where there was interposition between these
edges of one of the fragments. You understand from this how in-
exact it was to say, with Duhamel, that in every case there was a
complete periosteal ferrule which, by its ulterior transformations and
its interfragmentary prolongations, formed the whole callus. The
truth is that the periosteum contributes to a certain extent to the
formation of the callus, to a very great extent when it has not been
torn at all, or when, having been torn, the edges of the tear have
been brought together by the exact setting of the fragments, but to a
much less extent when the torn edges have been separated by a great
interval, or by the interposition of overlapping fragments. I am now
going to show you that nature has other resources than the perios-
teum, and that the repair of broken bones must not be attrtbutud Wi
this membrane alone.

68 FRACTUKES OF THE LIMBS,

2d period. — Look at tbeae four femurs (atill those of guinea-pigs),
which were fractured ten, twelve, fifteen, and twenty days ago.

I. Of not one of them have the fragments remained end to end, rb
happens when the experiment ia made upon a dog, and when immo-
bility has been obtained by means of some apparatus. Here I vas
not able to keep on any apparatus, on account of the disposition and
amallnesB of the limbs, and the vivacity of the animals. Therefore,
in order to describe to yon that which takes place when the fragments
are brought end to end, I am forced to refer to what I have observed
upon dogs in which I have obtained this result, and to the reports
of other experimenters who have observed facts of this kind.

In such cases, we find at this period, quite a thick capsule, adhe-
rent to, and enveloping the two fragments. This capsule appears to
be formed by the periosteum ; but it is doubled externally by a moa-
cular layer which adheres closely to it, and which yon will soon
verify upon our overlapping fragments. The union is so close, that
we may believe that the deep muscular layer has taken part in the
formation of this external callus. This capsule, which we shall
therefore name musculo-perio-Utn/, is much more dense than the former
ones; it adheres closely to the fragments, has a grayish ajipearance
on section, and when e.'iamined under the microscope, shows cartila-
ginous cells. In the earlier cases it was the fibro-cellular callus, now
it is the fibro-cartilaginoua callus. On section, we see a certain num-
ber of orifices, through which the blood oozes, and which belong,
some to the natural vessels of the membrane, others to vessels of new
formation. Here and there can be already seen a few calcareous
spots scattered through the thickness of the fibro- cartilage, and which
are the first points of ossification of the latter.

I do not wish to dwell too long upon the intimate mechanism of
the transformations which have taken place ; that of the plastic lymph
into a cellular, or connective substance for the new portion of perios-
teum ; that which brings about the thickening of the old periosteum;
then the invasion of the fibrous tissue by the fibro -cartilage, and the
bony deposits in the latter. Nor do I wisli to discuss the question
whether, instead of a transformation of the primitive elements into
others, there has not rather been a substitution, that is, a successive
replacement of elements and tissues by others. For these questions
are still under discussion, on account of the difficulty of settling
them by histological examination, and, furthermore, these studies
have no very direct clinical application. I will remind you only, in
order to enable you to understand these controversies, and their de-
gree of utility, that, at the beginning of the repair, and thickening
of the periosteum, we find in the organic gangue, rounded nucleated
cells, similar to those which precede the formation of our normal
tissues. Por the French school, represented by M. Chas. Robin,
these primitive cells are formed in the exuded lymph, which we com-
pared to a blastema. For the German school, represented by Vir-
chow, ihey come by proliferation from the cells of the torn tissue-
It makes but little difference to me whether you adopt the one or the
other of these theories, 1 have do unanswerable arguments for either ;

CONSOLIDATION AFTER FBAOTURK. 67

but I believe that the French opinion is better supported by observa-
tion than is the German.

A little later we find fibres of connective tisane, then cartilaginous
cells, and here again I am unable to aay if these are transformed
primordial cells, or if, as M. Robin' claims, the fibres have grown
beside and in the place of the latter, that is, by a substitution instead
of a transformation. As to the deposits of calcareous molecules,
soon supplied with thin bone, corpuscules, and vessels analogous to
those of Clopton Havers, no one ia able to say how they are formed ;
quite recently they have advanced the theory, without, however,
being able to prove it, that the corpuscules, or oateoplastea, were the
result of a calcareous infiltration of the primitive cells which I have
just mentioned. As for myself, I can suggest nothing else by way of
explanation, than a tendency, a niaus, analogous to that which must
be admitted for the primitive formation of the bones. This nisus
exists in the points of our organism where the skeleton is to form,
and it still exists in those where, a longer or shorter time after its
formation, a. solution of continuity occurs.

But, thus far, I have spoken to you only of the periostenm ; let us
DOW see what has taken place (when the fragraenla are end to end),
in the other partfl of the fracture, in the medullary substance, and the
compact tissue of the fragments themselves.

As for the medullary substance, as it is not well marked in these
small animals, I can show you only the anatomical modifications
which have been observed in the large animals, and even in the
human race. However, after separation of the fragments, and com-
paring the interior of the canal with that of the other side which is
healthy, you sec ia the centre of the bone a gray coloration, a J
greater density of the contained substance, and a diminution of the 1
fetty aspect. It is evident that the marrow has been modified in its
texture, and I do not think that I overstep the limits of permissible
hypothesis in telling yon that this marrow has been inflamed like the
periosteum. There has been mednllitia at the same time with perios-
titis. This inflammation has likewise given birth to plastic lymph, and
thia has been replaced by a fibro-cellular substance at the same time
that the fat has been absorbed. Ic is even possible that cartilaginous
oella have already appeared here. Thus far, I have not found any; but,
aa every one admits that the medullary substance becomes cartilagin-
ous, and then bony in the process of consolidation, I suppose that the
cartilage would soon have been developed, if it is not so already.
We have then here what the authors have named the internal fer-
rule, or the beginning of that part of the process of repair which ia
performed by the medullary substance. But, the work is not so far
advanced as it is on the side of the periosteum.

Now look at the end of the fragments. In the inter-fragmentary
space there is no appearance of consolidation; we find there only a
little blood, or, rather, sanguinolent aerosity, and if it were not for
the thickened periosteum and marrow, we could easily separate them

66 FfiA.CTUBEa OF THE LlMBa.

2dpenod. — Look at tbese four femura (still those of guinea-pigB),
which were fractureii ten, twelve, fifteen, and twenty days ago.

I, Of not one of them have the fragments remained end to end, aa
happens when the experiment is made upon a dog, and when immo-
bility hns been obtained by means of some apparatus. Here I was
not able to keep on any apparatus, on account of the disposition ftriA
smallnesa of the limbs, and the vivacity of the animals. Therefore,
ia order to describe to you that which lakes place when the fragments
are brought end to end, I am forced to refer to what I have observed
upon dogs in which I have obtained this result, and to the reports
of other experimenters who have observed facts of this kind.

In such cases, we find at this period, quite a thick capsule, adhe-
rent to, and enveloping the two fragments. This capsule appears to
be formed by the periosteum ; but it is doubled externally by a niaa-
cuiar layer which adheres closely to it, and which you will Boon
verify upon our overhipping fragments. The union is so close, thai
we may believe that the deep muscular layer has taken part in the
formation of this external callus. This capsule, which we shall
therefore name mtiscuh-jKiiostea?, is much more dense than the former
ones; it adheres closely to the fragments, has a grayish appearance
on section, and when examined under the microscope, shows cartila-
ginous cells. In the earlier cases it was the flbro-cellular callus, now
it is the fibro-cartilaginoua callus. On section, we see a certain num-
ber of orifices, through which the blood oozes, and which belong,
tome to the natural vessels of the membrane, others to vessels of new
formation. Here and there can be already seen a few calcareous
spots scattered through the thickness of the fib ro cartilage, and which
are the first points of ossification of the latter.

I do not wish to dwell too long upon the intimate mechanism of
the transformations which have taken place ; that of the plastic lymph
into a cellular, or connective substance for the new portion of perios-
teum; that which brings about the thickening of the old periosteum;
then the invasion of the fibrous tissue by the flbro-cartilage, and the
bony deposits in the latter. Nor do I wish to discuss the question
whether, instead of a transformation of the primitive elements into
others, there has not rather been a substitution, that is, a successive
replacement of elements and tissues by others. For these questions
are still under discussion, on account of the difficulty of settling
them by histological examination, and, furthermore, these studies
have no very direct clinical application. I will remind you only, in
order to enable you to understand these controversies, and their de-
gree of utility, that, at the beginning of the repair, and thickening
of the periosteum, we find in the organic gangne, rounded nucleated
cells, similar to those which precede the formation of our normal
tissues. For the French school, represented by M. Ohas. Robin,
these primitive cells are formed in the exuded lymph, whioh we com-
pared to a blastema. For the German school, represented by Vir-
chow, they come by proliferation from the cells of the ti>rn tissue.
It makes but little diftereooe to me whether yon adopt the one or the
otlier of these theories, I have no unanswerable arguments for either j

■ CONSOLIDATION AFTER FRAOTUBE, 67

but I believe that the French opinion is better supported by observa-
tion than IB the German.

A little later we find fibres of connective tissue, then cartilaginous
cells, and here again I am unable to aay if these are transformed
primordial cells, or if, as M. Robin' claims, the fibres have grown
beside and in the place of the latter, that ia, by a substitution instead
of a transformation. As to the deposits of calcareous molecules,
soon supplied with thin bone, corpuseules, and vessels analogous to
those of Clopton Havers, no one is able to say how they are formed ;
quite recently they have advanced the theory, without, however,
being able to prove it, that the corpuseules, or oateoplastes, were the
result of a calcareous infiltration of the primitive cells which I have
just mentioned. As for myself, I can suggest nothing else by way of
explanation, than a tendency, a nisus, analogous to that which must
be admitted for the primitive formation of the bones. This nisua
exists in the points of our organism where the skeleton ia to form,
and it slill exists in those where, a longer or shorter time after its
formation, a solution of continuity occurs.

But. thus far, I have spoken to you only of the periosteum; let ua
now see what has taken place (when ihe fragments are end to end),
in the other parts of the fruoture, in the medullary substance, and the
compact tissue of the fragments themseWea,

As for the medullary substance, as it ia not well marked in these
small animala, I uan show you only the anatomical modifications
which have been observed in the large animals, and even in the
human race. However, after separation of the fragments, and com-
paring the interior of ilie canal with that of the other aide which is
healthy, you see in the centre of the bone a gray coloration, a
greater denaity of the contained substance, and a diminution of the
fatly aspect. It is evident that the marrow has been modified in its
texture, and I do not think that I overstep the limits of permissible
hypothesis in telling you that this marrow has been inflamed like the
periosteum. There has been meduUitis at the same time with perios-
titis. This inflammation has likewise given birth to plastic lymph, and
this has been replaced by a fibro-cellular substance at the same time
that the fat has been absorbed. It is even possible that cartilaginous
cells have already appeared here. Thus far, I have not found any; but,
as every one admits that the medullary substance becomes cartilagin-
ous, and then bony in the process of consolidation, I suppose that the
cartilage would soon have been developed, if it is not ao already.
We have then here what the authors have named the internal fer-
rule, or the beginning of that part of the process of repair which is
performed by the medullary substance. Cut, the work is not so far
advanced as it is on the side of the periosteum.

Now look at the end of the fragments. In the inter-fragmentary
apace there ia no appearance of consolidation; we find there only a
little blood, or, rather, sangninolent serosity, and if it were not for
the thickened periosteum and marrow, we could easily separate them

e de UHviiine el d#, CUiratgle, ;a.i L\tU& eV Ba\iVvi <0-^^«K'^'^'

88 rBAOTUBES OF THE LIMBa.

from one another. Still the compnct tissue of the extremity of the
fragments ia red; if we detach the periosteum for a certain distance
above and below, we find the compact tissue pink and its vascalar
canalieuli eolarged. We have then here the anatomical charaeler-
isties of non-suppurating osteitis of the compaut tissue. I give the
Dnme plastic to that osteitis under the influence of which the exu-
dation destined to repair ia poured out, by opposition to the osteitis
in which there is formation of pus with or without a concomitant
reparatory process.

The anatomical modifications of this period in a fracture set end
to end may then be resumed in this: periosteum thick, fibro-oarti-
lagiuous, with beginning of ossification ; marrow dense, fibro- cell alar,
Boon becoming cartilaginous, but without bony deposit; no sign of
interfragmentary callus; osteitis on the surface and in the thickness
of the compact tissue of the fragments. In a word, repair by means
of the periosteum and the muscles more advanced than repair by the
other tissues.

II. We have now to see what has taken place in this second
period (from the eighth to the fifteenth day) in overriding fractures.
You still find here the fibro-cartilaginous condition of the periosteam
and the deep muscular layer, with beginning of ossification. But as
the periosteal capsule is incomplete that part of the work of r^air
which is performed by this capsule is necessarily less solid than in
the preceding case. As to the marrow, it is grayish and thick as
when the fragments are end to end ; but that of the upper and that
of the lower fragments no longer correspond on account of the over-
riding; consequently this thickening of the medullary substance does
not help the consolidation. But between the fragments there is a
fibro-cellular, partly cartilaginous substance which aids in keeping
them together. This is the beginning of an interfragmentary callUs.
But it is furnished exclusively neither by the marrow nor by the
compact tissue; it evidently has its origin in all the surfaces which are
brought into contact with one another by the overlapping. Such
are the outer face of the periosteum and a part of the compact edge
of the fragments. There, in a word, we must not seek circular
repair in the periosteum nor in the interfragmentary compact tissue,
still less in the marrow which contributes nothing to it since its two
divided surfaces are removed from one another. A mixed lateral
interfragmentary callus is produced, the materials of which are formed
by the muscles and by the outer surface of the periosteum, without
its being possible to prove that this latter is thickened and trans-
formed, and without our being able to admit anything else than the
effusion from it, as well as from the surrounding cellular and mus-
cular tissues, of plastic juices which are ultimately transformed. But
we must not expect to find regularity of the phenomena which we
observed in the end-to-end fractures, and which the authors have
erroneously indicated as occurring indiscriminately in all fractures.

Sdperiod. — Daring the third period, which lasts from the fortieth
to the sixtieth day, new anatomical modifications ensue in the libro-
saftjlaginoua substance which was formed during the second. The

mo
ieell

♦ ini

CONSOLIDATION AFTER FRACTOEK,

moat important is the formation of the bonv substance, that is, thsj
deposit of calcarenus matter, and the more abunclaDt deposit of oatetjiJ
ilastes or bone corpusolea. As for those latter, we may again asle J
lUrsetvea if they are the result of a transformation of the cartilaffinouil
^iftells or of a substitution. This is a point which histological observa- f
tion has not been able to clear up, and upon which only suppositional
are permiaaible. You know that I lean toward the theory of substl- :
tution.

Let us see what observation has taught us concerning the succea- 1
sioa of the phenomena in the different portions of the fracture ; and.f
here let oa diatinguiah again between an end-to-end and an over-
lapping fracture. The obaervationa have always been made upon '
the end-to-end fracture only. They have formed what I show you
here upon this guinea-pig's femur, the lesion of which has reached
the sixtieth day; a very large external bony ferrule; a bony mass,
a sort of internal ferrule, within the medullary canal, but an inter-
mediate substance between the fragments which ia not yet qait^J
ossified, and the greater part of which remains fibro-cnrtilaginonf'
In other words, you see here what Dupuytren described under the^
name provmonal callus, and Miescher under the nums primitu-e cailus.M
By these names these authors wished to indicate that the perioateaJT
and medullary portions of the bony callus were destined in greirf
part to disappear by absorption, and that the true oallus was formw*'
by what was left of these and by the bony substance which ultimatet^^
formed between the fragments. But there was an exaggeration oKl
the part of these surgeons in the expression of their thought in thiif 1
way, first, that all is not provisional in the periosteal and medullary'l
calluses, since a part is to remain; and secondly that, as I shalll
preaently explain, the theory given by them as a general one, ia uotf j
appliuJible to overriding fractures.

I ask you to notice, in passing, upon this human tibia, in which!
chance has permitted us to study a callus at the sixty-fiElh day, tbatj
Rt the level of, above, and below the fracture, which is not iin over-
Ibppingone, the compact tissue has become very vascular, very dense,
enlarged; that it offers, in short, the characteristics ascribed by
irdy to condensing osteitis. When I shall study the clinical phe-
iomena of fractures in detail I shall reuur to this habitual interven- j
tion of hyperostosis after fractures of the long bones. But here, j
while studying the question anatomically, I am justified in telling!
that the work of consolidation of fractures is dependent upon a ]
lodiflcatiou of the vitality of the fragments which we can ascribe to
lothing else than osteitis, and that the variety of osteitis which here
iterrenes is that which G-erdv named condensing osteitis. I go even
irther. In diaphysary fractures of long bones the intervention of
B condensing form of osteitis aeems to be necessary. When there
lack of consolidation and psoudarthrosia, rarefying osteitis has
ihitervened, Fortunately that is much more rare, and that is why we
00 rarely see pseudurthrosis follow simple fracture of the shaft of J
long bones.

Now let U8 luok at overlappiog fraotures. Wo have here ai^

70 FBACTURSS OF TH K LIMB

example in the femur uf n guinea-pig. I have sawn it longitudinally,
and you cmi see that tlie new ossification, or, if you prefer, the calci-
fication and profluctioM of oateoplastes, have taken place between the
two bony surfaces in contact, there where the fibro-cartilaginoua callus
already existed, but that there is no mention to be made here of a
medullary bony callus. It is true that the marrow at the Hne of the
fracture is in great part ossified. But you see that this ossification
is of no use to the callus and does not contribute to the consoUdatioD,
ince that of the upper and that of the lower fragment are not in
iontinuity as they were in the end-to-end fracture.

Nor is there any question of an interfragmentary callus formed by
the eompaot tissue. Consequently, we have no longer to speak of
provisional callus and definitive callus. Say, if you please, that the
lateral interfragmentary callus is perhaps larger to day than it would
have been six or eight months hence. But do not think that Dupuy-
tren's and Miescher's ideas are applicable to cases of this kind, which
are the most frequent in man. I have also to point out the same
hyperostosis consecutive to the condensing osteitis, as that of which
I spoke in end-to-end fractures.

ith period. — For the fourth period, which extends from the sixtieth
to the one hundred and twentieth day, and sometimes beyond, I have
but fev^ anatomical details to point out: the callus becomes denser
and diminishes io sine, the medullary canal generally remains filled
by the interior ossification, and the shaft of the bone remains a little
larger than is normal.

I have further to mention lesions which I can show you only
imperfectly in animals, and of whii;h I have at this moment no speci-
men belonging to man. But we often notice the consequences in the
living, I refer to —

IsC. Obliteration of the veins;

2d. Synovitis of neighbouring tendons and articulations;

3d. Muscular atrophy,

1st, Obliteration of the large veins near the fracture is quite a
common lesion, Are we to explain it by a phlebitis due to the pro-
pagation to the interior of the veins of the phlegmasia which arises
at the point of fracture, or is it due to simple coagulation of the
blood without preceding iuflammntion of the internal membrane of
the vens? The pathological anatomists are still discussing these
two theories. As for myself, I hold the first opinion. In most cases,
and especially in those in which this lesion occurs in the course of a
fracture, I attribute the coagulation of the blood in the veins to a
phlebitis by propagation, I even ask myself (but I shall never be
able to answer the question by positive facts) if this phlebitis is not
due to the passage into the large veins of irritating materials coming
from the inflamed marrow or osteomyelitis. But, leaving aside the
theoretical question, I point out to you this spontaneous coagulation
and the resultant obliteration as the cause of a complication which is
not dangerous, but is troublesome and lasts a long time, 03i,lema of
the limb about and below the point of fracture.

^d> Synovitis of the teudons and joints is not eo frequent in Irsia-

CONaOLIDATION AFTKB FaACTUKE,

711

res oP llie shaft as in those of the extremitiea of the long bones.
i, everlheleas, after one of the former yoa often see one of the neigh-
bouring joints inflame and preserve for a long time a more
painful rigidity, which is explained by the loss of extensibility am
of suppleness of the synovial membrane and the connective tissiii
which lines it. This is particularly common in the knee after frat
Jure of the shaft of the femnr, and in the ankle-joint after fracture
Sbe leg.

ad. The muscular atrophy consecutive to fractures which I ha
studied for several years, and which I made known in a thesis of Dr.
Lejeune' baaed upon my lectures at the HSpital Cochin, and a little
later in my work upon irreductibilily and the conseculive deformities of
long hones^ is a phenomenon, if not constant, at least very frequent.
We often see examples in living patients. The diminution in size of
the limbs, the diminution of strength, are easily recognized. In three
guinea-pigs whose muscles I here show you, this lesion is very evident.
The muscles of the thigh which was broken a few months ago are
little paler and smaller than those of the opposite side. I weighs
the muscles of the thiglis of one of the animals and found on th<
healthy side 142 grains, and on the fractured one 117.

Dr. Lejeune weighed separately the muscles of both limbs of
patient who died at the Hopital Oocliin, and found a notable difti
ence in each one.

According to these results, you may consider it an incontestable
that the muscles diminish in size after a fracture, and I have aseei
tained that this diminution is permanent, and not temporary.

I have sought^ for what might be the cause of this slight atrophy^
and reacheil this conclusion, that it should be attributed neither to
the compression nor to the immobility, and that it was doubtless due
to a change in the distribution of the nutritive materials which is the
consequence of the process of consolidation. Not only does the frac-
ture draw towards itself a greater quantity of these materials, but the
callus itself, when once formed, and after its completion the hyperos-
tosia, require a greater proportion for their nourishment. This seems
to me to be proved by the diflerence in weight between the fractured
and the opposite healthy bone of the same subject. For example,
look at these two femurs of a guinea-pig. The right, which waa
broken forty-three days ago and which is consolidated, weighs 19,
grains, the left, 15.75 grains. Is it not probable that the right hi
taken, and would have continued to take, if the animal had 1'
more material from the blood, and that consequeutly there wouh
have been lees left for the muscles?

Whatever may be the explanation, the anatomical fact exists and
.accounts lor the persistent weakness so loug complained of

itients in limbs which have been broken. I admit that in man;

itlents the diminution of strength is not great, and is scarcal;

5h.

' Lejenue, Tlifees do Paris,
' GoBiKlia, U^uioire sur I'l
lOQgj. (Sia. Hebdomad a ire >
) OMSvlin, \oa. oil.

?2 FBAOTURKa OF THE LIMBS. '

appreciable. That ia because the innervation is not affected, and the
muscles receive from the nerves a stimulus sufRcient to diminish the
physiological results of the atrophj. It is no longer the same when
the nerves have been wounded at the same time as the bone. Thern
may then be paralysis as well as atrophy, and the functional troubles
are muuh more marked. .^^

§ 2. FhENOMEKA of CONSOLlDATtON IN THE ExTTtEMlTlES ^H

OF Long Bones. ^|

111 the extremities of long bones, as in their shafts, we have a first
period, called inflammatory, during which the blood and the plastic
lymph are effused between the fragments, and at the same time the
adjoining connective tissue is swollen for a certain distance above and
below the solution of continuity. The beginning of consolidation
has not been so well studied here as upon the shaft, ibr the fractures
ore BO difficult to produce, that experimental study has not been possi-
ble, and on the other hand, occasions upon men are rare. We know,
however, that the fragments are almost never entirely separated from
each other, and that consequently we have not to make a separate
study for the end-to-end and for the overlapping fractures. They are
almost always end to end, with a more or less marked displacement
according to thickness and sometimes according to direction. On
the other hand, there is no medullary cavity, and consequently no
internal ferrule. The repair ia periosteal and interfragmentary, and
in this first period, the solution of continuity of the periosteum begina
its repiiir at all the points where its borders are a little separated.
But in general the periosteum does not thicken as much as it does on
the slialt, and does not form from the beginning this thick ferrule of
which we have spoken. No consolidation yet takes place between
the fragments; we find there only extravasated blood.

During the second period the new periosteal portion becomes fibro-
cartilaginous. At the same time the interfragmentary consolidation
commences by the production, probably through the transformatii>n
of the exuded lymph, of a Gbro-cartilaginous substance. But here
several varieties must be pointed out.

In the first, the fragments, composed almost exclusively of cancel-
lous tissue, have not been crushed; they offer neither the reciprocal
penetration so well described by M. Voillemier^ for fracture of the
lower extremity of the radius, nor the reduction into small fragments,
sometimes into dust, of a portion of this bony tissue which is broken
by the mechanism of crushing. In such eases the blood is absorbed,
and the fibro-cartilagiuous substance, the beginning of the interfrag-
mentary callus, is formed.

Iq a second variety, which is often found in fractures of the lower
extremity of the radius the pieces are in contact, but are reduced by
crushing into a certain number of fragments, some of which are very
smidi, almost pulverized. In such cases, especially when there ia
pciiL'tiaiiou, the work of con solid iition is preceded by the absorption

' Voillemiur, ClSuiiiae Cbirargioala, Paris, 18S1.

' CONSOLIDATION AFTBE FRACTURE.

of a part or of the whole of the fragmentary portions. Nothinj^
the clinical symptoms indicates this absorption, but as, after fractures
long consolidated, we find a shortening which cannnt be explainetlj
by overriding, and which we can attribute only to this absorption, "^
presume that it takes place during the first few days at the same tin
as that of the blood infiltrated between the fragments.

ITn a third variety, of which the intra-capsalar fractures of the nei
of the femur and of the humerus give us quite frequent exjimph
the fragments are in contact but do not penetrate one another ; thi
interposed blood is reabsorbed, and so too is the bone dust. But no
intermediate fibrO'Cartilage is produced, and this absence of the first
rudiments of a callus is the indication of non-conaolidatiou which has
been pointed out by all the modern authors as frequent in fractures
of this kind.

To what cause must we attribute this unfortunate result? It hi
been claimed to be due to the shortness of the upper fragment, tl
insufficiency of vessels, and therefore of nutritive materials, in this
fragment, and consequently the necessity for the lower fragment to
do the whole work of repair, a task which it is unable to perform
. properly.

I would here say that if this were the only cause, or even thi
feipai one, all fractures of the extremities would be exposed to noi
■eonsolidation. Now some of these, those of tlie lower extremity of
'he radius for example, consolidate very well.

In those which consolidate rarely I see the intervention of a ooi
iition which ought in great part to explain it; I refer to the free con
'"BQunication between the seat of the lesion and the articular cavity^
such as exists in intra-capsular fractures of the neck of the femui
I suppose that, as it has been claimed for fractures of the patella, tl
blood and plastic lymph flow into the articulation, and not enouj^
of the latter remains between the fragments to ultimately produce the
fibro-cartilaginouB substance.

In the third period, absorption of the pieces goes on if the conditions
of the fracture are lavourable thereto ; the periosteal callus ossifies
without becoming thick enough to form a ferrule comparable to that
of fracture of the shaft. The interfragmentary callus is completed
and assumes a greater and greater importance through the ossification
of the fibro-oartilaginous substance, according to the same mechanism,
and in the same mysterious conditions which I indicntiwl above. This
intermediary callus is often very thick and very resisting, especially at
the lower extremity of the radius; but sometimes, and in particular at
the neck of the femur, it remains fibrous and more or less dense,
almost always dense enough to allow the patient to walk with crutches
without inflection or rupture of the callus.

In any case, the capital difference to which I wish to call attention
between the callus of the shaft and that of the extremities is that, at
the beginning, the former is much more peripheral than interfrag-
mentary; that if it is interfragmentary in overlapping fractures, it la
at the same time lateral and periosteal ; while the second is interfrag-
mentary in the must rigorous sense of the word, that is, it is formed

res

th^H
no ^^

las

rea ^^

,in-
of

?4 FRACTURES OF THE LIMB

^M in great part or in totality by the spongy tissue through which the
^M solution of continuity was made. And the result of this comparative
^M study is to show that all the constituent parts of the bone, spongy
^m tissue, compact tissue, periosteum, contribute to repair fraotures of
^M the bone, that eveu the layers of muscular tissue and the surrounding
^B cellular tissue contribute also to it, and that, finally, the authors
^H erroneously attributed a much too large part to the periosteum in this
^M reparatory function Furthermore, the same conclusion will be drawn
^V from the study of the consolidation of simple fractures of flat bonea
^ and short bones.

In the fourth period, the patients are tormented by the conse-
quences of articular and tendinous synovites, and so much the more
so because these fractures being near a joint or synovial grooves, and
often even in communicntioa with them, the inflammation has spread
to the latter and left behind it the dryness and stiffness which in the
joints, characterize plastic chronic arthritis and dry arthritis. These
consequences are so much the more marked and rebellious because
the patients affected with these lesions of the extremities are almost
always hidvanced in age, for the predisposing cause of fracture vifitb
crushing is rarefaction of the cancellous tissue, rarefaction which, in
consequence of inexplicable modifications of nutrition, is a very
common consequence of age. Now it is also the case that in old
people traumatic arthritis and synovitis, although they do not go on
to suppuration, are very slow to end and often pass to that condition
of incurability which causes dry arthritis. Finally, muscular atrophy
occurs after these fractures as well as afier those of the .shaft.

§ 3. Anatomical Phenomena in Fractures of the Flat ^M
BoKES AND Short Bones. H

I have not much to say on this subject; nature uses the same
resources in the couaolidation of these two kinds of bone as in thai
of long liones. The muscles, the periosteum, and the whble fractured
surface furnish the materials, and the same ulterior modifications of
these materials cause the formation of the callus. But in the flat
bones, and especially in those which, have no diplo^, or only a very
thin one, the periosteum is the chief agent whore it has been pre-
served, and it must not be forgotten that if it has been divided, which
very commonly happens, it begins by repairing itseltj and tlie Tnaterial
which it supplies to the callus comes as much from Its cicatricial
portion as from that which remained intact about the fracture.
Further, no matter how thin the bone may be at the place of fracture,
it can still furnish the materials needed for repair. I had occasion,
in 1871, to trepan for intra-oranial suppuration following gunshot
fracture of the right parietal boue, ayoung man twenty-four years
old, who was emiiloyed in the museum of natural history, and had
been brought to the ambulance of that establishment after the battle
of Buaenval, where he had been wounded. Not only did he survive
the operation, but a bony growth formed all around the opening and
advanced towards the centre, so that this sort of fialtened callus

COMPOUND SUPPURATING KRACTUBB8.

losed entirely the hole made by the crown of the trepan. Larre;

IR3 reported similar cases, in which, as in mine, the calluses were'
formed during suppurative osteitis, but I wish to mention them here
in order to show you once more the power aud the multiplicity of
means which the organism possesses to repair not only solutions of
coatiauity but also losses of substance in the bone.

LEOTURE X.

]

;ating ^I

■fat Vs-riet J : Consolidatiou after benign and aupHrScial siipparntiug oateiLis. 2d
Varietj ; Consolidation after deep osteilis or uou-piitrid siippuratipa ost«o-mye-
Utia. 3d Variety ; Death before oouaoliialion by putrid osleo-myelitis and
paralent infeotion.

Gentlemen : Do not lose sight of a first point which is capital in
history of fractures complicated by wounds; they may get well,
Exactly like simple fractures, but on one condition, which you should
^always bear in mind when you are called upon to treat such a case,
1 condition, I repeat, that the bone does not suppurate.
When the broken bone suppurates, and unfortunately all the efforts
bich you have made and should have made to prevent it do not
succeed, the clinical and anatomical phenomena of conaolida-
: peculiarly modified, sometimes hindered by this new compli-
ition which I shall study especially in the long bones.
Moreover, we bave differences depending upon whether the suppu-
;ting osteitis occupies the superficies or the entire thickness of the
me, and according to its greater or less intensity. Let me explain

two points.
1. In a first variety, which I call heniffn and svperjictal suppurating
Ileitis, the patient has no general symptoms and consequently no
iver. The swelling of the limb is moderate, suppuration is estab-
the fourth or the fifth day in the wound itself. The eschars
begin to be eliminated, and if you probe the wound gently, you feel
the bone denuded superficially. Suppuration becomes a little more
abundant after the eighth or ninth day, but the pus is laudable, not
"itid, and the apyrexia continues. Things go ou in this way for
fWenty or thirty days; the suppuration continues rather scanty, with
10 burrowing of the pus, no indication of a deep collection. Mobility
of the fragments begins to diminiab ; in short, except for the superfi-
cial suppuration and denudation, the fracture resembles a simple one
that has reached this period. But the denndaUow 'i'.iv.\.\'p.'^^% wii.'Ji*.
fracture goes on to the sixtieth, sixly-Mlh ift^j y, ^^vvV "C^^J^^^^

'76 FRACTUBSS OF THE LIMBS,

day we find it consolidated. locreaaa of volume can be felt above
and below, showing that the osteitis on both sides of the fracture
has taken on the condensing form with which we are acquainted.
But the fistula persists and the suppuration which it supplies onl_v
ends twenty, thirty, or forty days later, after elimination of a splinter
or mortified piece comprising a more or less considerable portion of
the thickness of the bone. To use the ordinary terms, there has
been aaperficial necrosis, and, after espulsion of the necrosed part,
the callus and cicatrix have beeu completed. The osteitis, instead of
remaining plastic over the whole fracture, became suppurative and
necrotic in one place, hence the anatomical phenomena which have
taken place. In the deep parts of the bone, that is to say, between
the fragments, in the medullary canal, and at that portion of the
circumference of the bone which is opposite that with which the
wound communicates, the osteitis has been plastic, that is, non-suppu-
rative, and the' callus has beeu formed, as in ordinary cases, by
effusion and ultimate transformation of the lymph. Adjoining the
wound the periosteum has been destroyed by absorption or by
mortification; part of the bone has necrosed. Suppuration has taken
place about the necrosis without extending to the interfragmentary
space. After expulsion of the sequestrum, the suppurating granula-
tions have covered the surface of the bone, and it is in them that
have taken place the ulterior transformations, that is, into fibro-
cartilage, and then into bone, which have brought about both the
reproduction of the periosteum at this point, and the reproduction,
sometimes excessive, of the subjacent layer of bone. Here theu you
see a new element intervene in the formation of the callus, an element
which is itself a product of the consecutive inflammation ; the granu-
lations, which whilst they suppurate on the surface, ossify below and
are transformed into a bone cicatrix, just as they are transformed
upon the skin and subjacent tissues, when there is suppuration, into
inodular fibrous tissue. The intervention of this new element shows
you once more how many assistants the periosteum needs in order
that the callus may form under all the conditions where its produc-
tion becomes necessary.

2. In a second variety, suppuration invades the surface and the
depths of the bone, that is to say, the interfragmentary space, the
medullary canal, and that portion of the circumference which is
furthest from the wound. The osteitis, in a word, has become a
general suppurative one, and is no longer partially suppurative as in
the other variety. This is the form which we call suppurative osteo-
myelitis, BO as to indicate also the participation of the marrow.

At first the clinical phenomena vary according to the intensity of
this osteo- myelitis. If this is moderate, if the osteitis is subacute,
the primitive or traumatic fever is not very violent; the pulse does
not go beyond 100, 110, nor the temperature in the axilla above 101°
to 102" ; you do not see the subicteric tint, the delirium, the dryness
of the tongue, the tympanism of the abdomen, which announces the
dangerous form of traumatic fever. Suppuration begins on the fifth
fr sixth day in the wound ; the pua burro'Ns m Uie neighbouring

r COMPOUND SUPPaEATING FRA0TDRK3. 77

tissues. Through the wound anil the new openings made by the
suppuration, the probe, and sometimes the finger, show that the bone
is denuded to a considerable extent above and below the fracture,
both about the wound and on the opposite aide. The probe pene-
trates deeply between the fragments and brings out pus. If in order
to dress it, you are obliged to move the limb, you see at each more-

tment the liquid escape from the deep parts; furthermore, the suppu-
ration is very abundant. These are so many indications of the
presence of suppuration in the depths of the bone, and consequently
in the medullary canal.

The case goes on thus for weeks and months unless complications,
particularly erysipelas or purulent infection, should intervene.
Suppuration continues to be abundant, from time to time slivers of
bone are eliminated, the fragments remain movable, repair does not
go on, and yet the tumefaction of the bone above and below the
fracture indicates that there the osteitis has become condensing, a
circumstance which generally augurs well, because, in cases of this
kind, the osteitis is reparatory at the same time that it is condensing,
that is, the niaus which increases the size of the bone above and
below the fracture tends also to repair it.

Finally after a length of time which varies from three to six
months, a large callus exists at the seat of the original lesion of the
bone. There are still superficial alivers of bone, others, surrounded
by new bone, are invaj^inated; more or less numerous fistulte lead to
these sequestra. In short, the suppurating osteitis has at the same
time been bypertrophying and necrotic, as is generally the case in

I acute suppurating osteitis of youth, and finally, the fracture is really
replaced by necrosis consecutive to this osteitis.
How is this callus produced? Very probably bythe two mechan-
isms which we already know; in spite of the intensity and abundance
of the suppuration there are perhaps here and there a few points
where it has not taken place, and where the plastic exudation has
been deposited either by the muscles or by the portions of hone
furthest removed from the wound. But in addition, at those points
where suppuration takes place without necrosis and elimination, the
callus is formed by the granulations themselves, as Sabatier formerly
pointed out, and as well by those of the medullary caiial and compact
tissue as by those of the periosteum. Another proof in support of
the opinion that the periosteum is far from beiug the only agent in
the formation of the callus.

3, In a third variety, the osteo-myelitis becomes as intense as
possible; it is hyperaoule, gives rise to traumatic fever of the most
dangerous kind, and is followed, if life is prolonged, by putrefaction
of the marrow and periosteum which becomes the point of departure
of that other fever which we call purulent infection. But I do not
wish to treat to day of putrid osteo-myelitis. I only wish to point
it out to you, placing it beside the other forms of suppurating osteitis
and the mode of corisoliduliou after their appearance. ~

FKACTUKKa OF THE LIMB

LEGTVRE XI.
FRACTUKES OF THE LEG.

Fracture by indirect aotion at the janotioii of Ilia raiiJdiB with the lowei
leg — Esamiiiatiaos made to reoognize it — No appreciable displao
Variety, Clinical— Mobility, Crepitation— T lie fractare occupies both bouea —
Search for tlia direction — Esplanation oF tlie ab^ience of displacement. 2d
Variety, Clluical — Indireat fraotnre nitli transverse displacement — EzaminBtiou
of these three qnestiona — Wliy this diaplaoeiQout ? — U it redaoiblo and eaally
maintained ! — What ia the cause of tlie plilyoteuffl, and what will they beooma f —
Traiitmeut with tlie wire splint — Deaorlptiou of Soultet'a apparatus, meohaoleal

Gentlemen; I. Yon have just seen in No. 5, a man 32 years ol
of habitually gooiJ health, who fell yesterday evening in the stre(
was unable to rise, and was brought to the hospital on a stretcher.
He was put to bed and bis left leg placed in a wire trough extending
a little above the knee. The patient suffered during most of the
Dight, and has slept but little; this morning we find him in the
following condition : —

The left leg, compared with the right, \si notably larger, without
ehowing either phlyctenge or redness. Pressing with one finger upon
the inner face of the tibia we feel only a little thickening; there ia
neither ecehymosis nor phlyctense. The finger passed along the
anterior border and inner face of the bone, finds nowhere any in-
equality which could be attributed to a displaced fragment. Pressure
with this finger causes pain only at the junction of the middle with
the lower third of the leg. This pain on pressure in a fixed point,
the suffering experienced during the night, the extensive thougli
moderate swelling, taken together with the difRculty of moving the
limb, and the patient's inability to get up and walk, are the rational
signs of fracture. But you saw that by raising the limb with my
two hands, one of which embraced its middle, the other its lower
third, and by trying to move the lower part of the limb alternately
outwards and inwards with the hand which held it, while the other
held the upper two-thirds firmly, I produced an abnormal movement,
the centre of which was at the lower part of the shaft of the tibia.
I thus demonstrated mobility, and during the same manceuvre I also

I felt crepitation. We have then no doubt upon the first point of the
diagnosis. The patient has a fracture.
But is it only a fracture of the tibia, or are both the bones broken ?
It is again the mobility which enables us to answer this question. If
the tibia alone had been fractured, I should have been able to impreaa
only very obscure movements which would have left me in doubt;
to establish my diagnosia I shou\il \ia\e Uad lo \ws\at w^u^a, the jiain

FRACTUBES OF THE LEG.

on pressure, and to renew the examiDatioo for several successive days.
I should undoubtedly, after several days, when the swelling and the
muscular contractions had diminished, have ended by finding a suffi-
ciently appreciable mobility ; perhaps also one day or another, during
these examinations, I might have found crepitation. But when the
very first day you find a mobility so marked that the hands of the
Burgeon appreciate it very easily, and that even the assistants can see
it, there is no hesitation ; it is a simultaneous fracture of the tibia
and fibnla.

Can I now tell you what is the direction of this fracture, if not in
both bones, at least in the more accessible one, and to what anatomo-
paihological conditions the absence of displacement is due? Upon
these points I am obliged to maintain the greatest reserve. Before
Malgaigne's publications we might have thought that it was a trans-
verse fracture; but since Malgaigne' has shown positively that frac-
tures of this kind, especially in adults, do not exist, and that the cases
which were supposed to be such were toothed fractures, we may
believe that we are in presence of a fracture of this kind, and that
the non-displacement is explained by the preservation and interlock-
ing of these irregularities. It is probable at the same time that the
periosteum and attachments of the muscles are preserved upon a
part of the contour of the solution of continuity, and aid to keep the
fragments together.

However that may be, you are in presence of the most favourable
cliniral variety. The patient will get well without deformity, and in
all probabdity will get well rapidly. At least we foresee no circum-
stance which would retard consolidation.

II, Not far from this patient ia another, at No. 15, who was admit-
ted three days ago, and who presents an example of the second
clinical variety of fracture of the leg.

He fell, like the preceding one, and was not able to get up or walk.
It was the left leg which was injured. The functional and physical
symptoms are the same. But in addition, by passing the finger along
the anterior border of the tibia we felt at the lower part of the
inferior third an abnormal projection which raised and distended the
■skin and was painful on pressure. Furthermore, there were two
quite large phlyctenaj, one of which was filled with yellowish aerosity,
and the other with sunguinolent serosity, and a tew smaller ones.
Let us consider for a moment these two particularities,

Ist. What ia this abnormal projection? It is evidently formed by
the upper fragment of the tibia, and is due to the fact that this frag-
ment, pushed forward by the impulsion which was communicated to
it at the moment of the accidcriL, ia at the same time drawn up and
held by the traction of the quadriceps femoris upon the point where
the ligamentum patella is attached. This displacement, the most
frequent of those which you will see in fractures of the leg, belongs
to the category of transverse displacements. When you meet with
it, you will ask yourselves two questions : one theoretical. To what
is it due ? the other essentially practiuai. Is it reducible?

' Alal^aigue, Tiaita des li&QWjg^'SL

FBACTUHK3 OF THE LIMBS.

To what ia it (\ve? I told you a moment ago that it waa due
to an impulsion forwards by the cause oF the injury, and to the
action of the quadriceps femoris. But the anatomical condidoa
which really explains it is the principal direction of the line of frac-
ture. This direction, instead of being nearly horizontal aa in the
preceding case, represents an oblique direction downwards and f or

» wards, a section so disposed that the apper fragment terminates^^H
a more or less pointed extremity. This disposition has received 1^^^|
name of oblique fracture, and you understand that it is very favoij^^^l
able for the displacement which we see here. It is sufficient that ^^^

able for the displa*

tlie time of the accident an impulsion be communicated to this frag-
ment, so that, drawn up by the action of the quadi'iceps, it forms the
projection which yon saw.

Are there not, also, in the manner in which the fracture is produced,
in its mechanism, as they say, reasons which explain the displace-
ment ? I do not think so, or at least if the reasons exist, they escape
us entirely. For I learn from the information given by the patient
that, as in the preceding case, the fracture waa produced without the
intervention of any more or less heavy vulneraiit body. It is not
then a fracture by direct action, but by indirect action. But in
fractures of ihia kind which we are unable, on account of the re-
sistance of the tibia, to reproduce upon the cadaver, the solution of
continuity ia the result both of irregular muscular actions, some of
which tend to give the bone an unusual curve, aud the others to
twist it, and the pressure of the weight of the body upon this bone,
already a little bent and twisted. But it ia impossible for us to
analyze strictly the muscular phenornenu which are produced at the
moment of the fall; and as it is also impo.ssible to study them by
experiments upo^ the cadaver and upon living animals, I am unable
to tell you how and why, in consequence of this complex interven-
tion of muscular action and the weiglit of the body, there is obliquity
of the fracture aud propulsion forwards of the upper fragment of
the tibia.

Content yourselves, then, with knowing and remembering this
capital fact; the most frequent displacement in fractures of the leg
is the one you see here, a transverse displacement in which the
extremity of the upper fragment projects forwards.

Let us now consider the practical question : Can this displace-
ment be reduced, and will it be possible for us to keep it reduced, so
that the patient may get well without a deformity due to the per-
sistence of a transverse displacement? This problem is in great part
solved for this patient. For yesterday I reduced the displacement in
the following manner: T raised the leg from the wire splint in which
it had been placed the evening before. With one hand I held the
upper fragment; with the other, grasping the two malleoli, I drew
them downwards, exerting what, in classical language, ia called exten-
sion. As I felt a little resistance I asked an assistant standing at the
end of the bed to help me make extension, grasping the instep with
one hand, with the fingers upon the dorsum and the thumb upon the
sole of the foot, and the calcaneura with tlie other. I aalied him to

FKACTURKS OF THE LEG. 81

draw on the foot while I myself exerted traction with the left hand
and made counter extenaion with the right. The projectioa having
disappeared, we replaced the limb in the trough well lined with
cotton ; I satisfied myself that the coaptation eoiitinued ; and, fearing
lest in the manoauvre an angnlar displacement might have been sub-
stituted for the transversa one which we had juat corrected, I looked
to see if the foot was in a good position, drawing an imaginary line
from the middle of the first metatarsal bone to the inner border of
the patella. When the foot is in a proper position, this line ia
parallel to the axis of the leg.

As this condition existed, I concluded from it that the reduction
had been well made. I asked the patient if he felt any painful prea-
sure on the heel; he said he did not. For greater secnritj I placed a
supplementary pad of cotton behind the tendo Aehillis above the
posterior projection of the calcaneum, so as to diminish pressure on
the latter — pressure which is the cause of the severe pain so much
complained of by many patients with fracture of the leg. I com-
pleted the dressing with a bag filled with oat chaff placed upon the
front of the leg, an anterior splint, and some straps with buckles. I
examined the leg yesterday and this morning, and found, by passing
my finger along the inner face and the anterior border of the tibia,
that the fragments were kept in place. I have now no doubt that
they will remain so until the end of the treatment. You will then
have seen upon this patient one of the most frei^uent forms of frac-
ture of the leg, that is, fracture with transverse displacement, re-
ducible and easily kept reduced.

3d. What are we to think of the phlyctense and of the inSuence
which they may have upon the course of the disease ?

In themselves they indicate nothing bad. They are due to a
singular modification of nutrition which follows traumatic perturba-
tions. More frequent perhaps when the fracture is direct, they occur
also, as you see in this patient, after the intervention of indirect
causes. They accompany fractures of the leg much more frequently
than those of other parts of the body. Why ? It is absolutely
impossible for me to tell you.

As to the influence which these phlyctente will have upon the
course of the disease, I consider it very simple. I cut them open
with the scissors, let out the aerosity, and placed upon each of them
a small piece of perforated linen ; and, as the surface of the derm ia
neither very much bruised nor sloughy, I presume that they will
dry promptly, without suppurating, and that in a few days tbey will
be healed.

You will sometimes see phlycteuie of the leg followed by suppura-
tion of the derm for ten or fifteen days. You may also find under the
raised epidermis an eschar, not comprising the whole thickness of the
derm, but which nevertheless will have to be eliminated; hence a
euppuration which may last long enough to necessitate a special dress-
ing every morning and to oppose the application of the immovable
apparatus. This suppuration of phlyctente, with or without

I
■

■
I

FRACTDBES OF THE LIMBS,

seldom seen except in cases where there lias been intervention of a
direct cause and more or less violent contusion of the sirin.

In short, the prognosis in this patient, as in the other, ia favourable

a this sense, that the cure will take place without persistent deformity.
But it has this disadvantage, that, whatever we may do, the patient
will be obliged to keep the bed for about sixty days, walk with crutches
for from four to eight weeks, and then with a cane, slowly and limping,
for a certain time. The most favoured adults, after a fracture of the leg,
do not walk in a perfectly satisfactory manner before the end of four
months.^ Perhaps ours will not be such. Many conditions which we
cannot foresee, but which nevertheleaa may easily intervene, may per-
haps ultimately appear. Thus I advance the opinion that the callus
i solid and that mobility will have disappeared after 45 days.
But who knows whether in them, as happens from time to time, and
without our being able to know very well or foresee the reasons, 60,
75, and even 80 days, instead of 45, may not be necessary to obtain
this result? Who knows also whether the tibio-tarsal and tarsal
articulations will not remain painful and stiff for many months? I
do not think so, because the patients are still young, and are neither

outy nor rheumatic, and because I have no reason to suppose the ex-
istence of a Assure extending into the articulation ; but, whatever naay
be the favourable presumptions, you should know that in many cases
fracture of the lower third of the leg is followed by an arthritis end-
ing in a semi-anchylosis which long remains rebellious and painful
during walking.

You have seen in what the treatment has thus far consisted. The
leg is kept quiet in the wire trough by means of three canvas bands
which are properly lightened and buckled in front over a splint, be-
hind which is a chaff-bag. The foot is also fixed to the sole of the
frame by a figure-of-eight bandage, the loops of which surround the
apparatus, one opposite the lower part of the leg, the other opposite
the foot.

Immobility is assured by means of the mechanical bed which we
use for all fractures of the leg and thigh, and even for all painful dis-
eases of the lower limb. The one which we use in the hospital is more
simple but a little less convenient than those which we make use of
in private practice, and it has the advantage of being easily arranged
everywhere, even in the country. It is composed of a rectangular
oak frame, the length and breadth of which are the same as those of
the mattress. At about 18 inches from the upper end is fastened, by
means of a hinge on each side, another smaller frame, intended to hold
the pillow, and capable of being fixed at any angle. This smaller
frame has but three sides, the one between the two hinges is lacking,
and is covered with a stout piece of canvas. The corners of the largo
frame are furnished with stout hooks, and smaller ones are placed at
intervals along the sides, by means of which sheets or strong sail-
cloth bands, 6 to 8 inches wide, can be fastened upon the frame. Two

Uren oonaolldaKon takea pUoe n
toe tlieir funulions anouer, ao tliat
iMftt tliu eud of tno luoutUa walk quite ei

FRACTURES OP THE LEG.

pbrds, the four en(3s of wbicb are attached to the corners of the frame, I
tad a pulley, whose hook receives their loops, complete the apparatus. ]
The upper pulley is attached to the ceiling, or to the frame of the bed I
1 our hospitals.

Fig. 4.

osplUl B«d.

The patient is placed in the iniddle of the frame, which has prevl
ously been arranged with five or six bands. By means of the small
frame his head can be raised for the purpose of eating or drinking,
without causing the least sudden movement. If the bands are not
properly placed, new ones can be easily substituted by raising the
frame a little or by passing them under the patient as he lies, and
attaching them to the hooka. By raising the frame with the cord and
pulley, the wants of nature can be attended to, proper cleanliness ob-
served, and the bed and bedclothes changed, all without giving the
slightest injurious movement to the limb.

As our patients are young and healthy enough to endure without
pain the prolonged pressure of the sacrum upon the bed, I do not usa
the water-bed, which, however, I should make haste to employ if, after
a little while, they should complain of pain and sores in that region.
I should have recourse to it at once if the patients were weakened by
age or by anterior diseases.

The beds occupied by these two patients are in a well-lighted part
of the ward. That is a point which should always he seen to. Light
is necessary to the maintenance of good health, aad good health favours
the formation of the callus.

I saw at the Hotel-Dieu, in 18-17 and 1849, two patients who had
been lying for six weeks in the darkest part of ward Sainte Marthe,
and in whom a fracture of the leg was not at all consolidated. I had
these two men placed in better lighted beds in the centre of the ward,
and consolidation took place at once.

It is unnecessary to say that the patients will be nourished as well
as possible, and that the lirab will be examined from ti-ma Vi v.v-^a'wi

I
I

84 FRACTUKKS OF THE LIMBS.

make sure that no displaeement tas occurred, and, for the one wWcb
baa the pblyctenffl, to renew the cerate dressing which ia applied to
them.

In fifteen or twenty days, when the inflammatory period ia ended
and there ia no more swelling, and when the second phase of the affec-
tion has begun, during which we have fibro-cartilaginous transforma-
tion and the beginning of calcareous deposits in the soft, sanguinolent,
and glutinous substance which forms outside the bone and inside the
medullary canal during the first period, you will undoubtedly see me
change the apparatus : I shall envelop the limb in a layer of cotton,
and wrap about it first a dry band and then another soaked in dextrine
or silicate of potash. This band will be left in place for twenty or
thirty day.s. When I wish to remove it, I shall place the limb in
warm water for half an hour, and then, the bandage being thus softened,
take it off carefully, while the leg is held by two assistants, so that no
shock may be communicated to it in case consolidation should not be
sufficiently advanced.

The bandage removed, I shall see if any mobility remaiug; it is
probable that I shall find none. The rule is that it does not last until
the forty-fifth day in fracture of the leg in adults. Does that mean
that the callus is complete and perfect at that period ? By no means,
it only means that it is solid enough to resist the lateral impulsion
which one hand gives the lower fragment while the other one holds
the upper one immovable. But a few anatomical studies which I
have had occasion to make upon fractures at this period in man, and
the analogy with that which we 6nd in the bones of animals subjected
to experiment, oblige me to admit that, notwithstanding the disappear-
ance of abnormal mobility, the callus is still in part fibro-cartilaginous,
and is not so exclusively bony as it will become. These same studies
have also taught us that it is only the peripheral periosteal callus
which has become solid and partly ossified; but that the interfrag-
mentary callus, so well demonstrated by M. Lambron,' is still soft and
without admixture of calcareous molecules and bone corpuscles.

Finally, clinical experience has taught ua that if the patients now
begin to walk, the callus may bend, yield, and an iterative fracture be
produced. In a word, the callus will be so solid on the forty-fifth day
in both patients that mobility will no longer be felt; but not suffi-
ciently solid to allow us, without danger, to subject it to the trials of
walking or even standing. Therefore we shall advise them to remain
a fortnight longer in bed, and not to begin to walk with crutches until
the sixtieth day. By that time the peripheral callus will have com-
pleted its ossification, and the interfragmentary one will have com-
menced and will be able to continue and complete its own notwith-
standing the movements and exercise of the patients. As its ossifica-
tion advances, the volume of the exterior callus will diminish.

But let us return a moment to the treatment which I have began
and which I propose to continue in both patients. I want you to
nnderstand that I might employ many others and obtain an equally

' Lwobioii, Etndefl ■or lei Formations do Cal, Paris, 1842.

FRACTUHES OF THE LEG. 85

good reault. You will find in your text-books the description of a
certain number ofapparatusesfor fractureaof theleg, andyou majeven^
by eonaulting a masterly thesis writien by Malgaigne,' make your-
selvea acquainted with all the inventiona bearing upon this point
which have been produced since the days oF Hippocrates. They are
very numeroua; and indeed any one of them might do for our preaent
patients. For when we find ouraelvea in presence of a fracture with
a displacement which it ia easy to reduce and keep reduced, all appara-
tuseaaregood if they are sufficiently restrictive and if the patient will
keep as quiet as possible. You will then be able, in your practice, to
employ, instead of this wire trough, one made of tin, gutta-percha, or
wood. Above all, you will be able to use the system of short separate
bands, called Scultet's ajiparatua. Ita advantage ia that it can be cou-
Btructed everywhere out of materials which are almost always at hand,
and which, if necessary, can be replaced by others quite aa easily found.
Before applying it, it is to be prepared in the following way; —

Arrange upon a table three or four cords parallel to one another, or,
better, three or four bands of stout duck or elastic webbing furnished
with buckles. Over these place a large napkin or towel; upon this
towel you place small bands, three inches in width, whose length 19
double the circumference of the limb; each band overlaps ihree-quarterg
of the breadth of the preceding one. Tliey are to be placed perpen-
dicularly to the axis of the limb, beginning at what is to be the upper
end of the apparatus and continuing until you have obtained a length
equal to that of the injured limb. Upon these bands, and beginning
at the same end, you place doubled compresses five inches wide, each
of which covers half the breadth of the preceding one. A splint, as
long as the limb, is then placed along each side, and the towel, bands,
and compresses rolled over them until they meet in the centre. Thua
arranged, the apparatus can be easily transported.

To apply it, the assistant, who makes the extension, raises the foot,
drawing it towards himself, while the surgeon, seizing the leg with hia
left hand (if it is the right leg) above the fracture and with his right
hand below, maintains the reduction. Another assistant places the
bandage under the limb, and, unrolling the splints, spreads out the
apparatus. The limb is then placed carefully in the centre, and, while
the assistants keep up extension and counter-extension, the compressea
and bands are freely wet with a mixture of two parta of water and one
part of camphorated alcohol. The surgeon then takes the lowest com-
press by one end, while an assistant holds the other, rolls it smoothly
over and engages ita end under the limb on the opposite aide; he then
brings over the other end and tucks it under on his own side. He
does the same for each compress, one after the other, and then applies
the bands in the same way. He then rolls up the outer splint in the
towel and places a chaft'-bag, an inch thick, between it and the leg;
an assistant does the same on the opposite side, and the apparatus is
completed by means of an anterior bag upon which is a shorter splint.

FRACTURES OF THK LIMB3.

The assistant then holds the three splints in place while the surgeon
ties or buckles the straps. Ho takes care that the hee! does not preaa
upon the beil, so as to avoid those intoleraVjle pains which are some-
times caused by continuous pressure of the calcaneum. If this pain
occurs the surgeon plaoes a small square cushion under the lower part
of ihe leg so as to raise the heel from the bed. A hoop or cradle pro-
tects the leg from the weight of the bedclothes.

Sometimes the point of the foot has a tendency to incline to the
right or left. I then fix it in a good position by means of along com-
presB wrapped about it and fastened on eauh side to the bed. The
foot ia in a good position when a line drawn from the patella to the
great toe is parallel to the axis of the teg.

I advise you to familiarize yourselves with the construction and
application of SculteJ's apparatus; for in private practice you will
often employ it. But, when you make use of it, do not forget one
principal precaution, that of not making it too tight at first. It has
been often discussed whether it is better, for fractures in general, to
reduce them and apply at once the restrictive apparatus, or to wait
until the inflammatory period is ended. That is a question which
should not be examined generally; its answer varies according to the
regions.

As for fractures of the leg, it is incontestable that the patients feel
better and suffer less when the limb is kept in a good position. I ad-
vise you then to apply the first day the restrictive apparatus which
you may select. But do not forget that the limb will swell, on account
of the distant infiltration of the blood which continues to be poured
out by the fractured surfaces, and of the aerosity exuded during the
inflammatory process. Consequently it must not be tightly applied
at first, for a slight constriction might be turned into a strangulation
by this inevitable increase of volume. Of course, in a limb so well
supplied with muscles and whose arteries are so well protected, gan-
grene is not to be feared, at least in an adult, but the constriction
might cause new phlyctente, and, above all, it would have the dis-
advantage of causing the patient to suffer, of preventing sleep. Now,
our duty is to avoid causing useless suffering, and, moreover, suffering
affects the health.

I told you that to have a regular and prompt consolidation it was
necessary that the general health should be troubled as little as possi-
ble. With troughs and straps we can easily avoid too much constric-
tion, and if by chance it should be too great, any one can loosen the
straps without disarranging the apparatus. With Scultel's apparatus
this is not so; when the constriction ia painful, it is necessary to await
the arrival of the surgeon, and consequently long suffering ia need-
lessly inflicted upon the patient. You will avoid this by not tighten-
ing at first, and by renewing the application every day so as to pro-
portion the compression to the increase or diminution of volume.

I have sometimes used Malgaigne's box, or Jules Roux's planckette
polydactyle.' The latter is very convenient, especially if you take care

« pasaed to preas upon the

FBACTDBaa OF THE LEG. 87*

'.t well with cotton or with a sheet, and if the holes through^
'hich the pina are to pass, are numerous enough to furnish, on each
aide of the foot and leg, aufficieot support for the limb.

These apparatuses have the advantage of allowing the surgeon to
easily uncover the fractured limb to see what is going on, treat the

■ phlyctenis, arrange the degree of constriotion according to the change

-'-1 size, and make, if necessary, a new reduction. Among these appa-
ituses, I may even estabUah a distinction between those which leave

i^e anterior part of the limb uncovered, and those which allow the
fractured point to be seea only after they have been entirely, or in
part, removed.

The first, which I also call open apparatuses, are the troughs, wheo
tbey are not closed by means of the anterior splint and strips, Koux'a
planchette polydaetyle, the simple cushiontrough which I have some-
times used, and which consists of a large square cushion, filled with
oba&i upon which the leg ia placed, and then its sides are turned up
and fastened with straps, taking care to leave aa open space in front
through which the leg can be seen and felt. I might add, as forming
part of this category, Maisonueuve's plaster splints. They are made
of two pieces of linen, folded in eight thicknesses, and long enough
for one of them to pass along the back of the leg and sole of the foot
to the ends of the toes, and for the other to encircle the sole of the foot
like a stirrup, and pass up each side of the leg aa far as the knee.
These pieces of linen, dipped in plaster, and folded so as to be two
and a half inches wide, are applied to the leg, and kept in place by a
roller bandage until they become dry, when the bandage is removed,
md three strips of diachylon substituted, one about the foot, the other
'o about the leg, leaving a part of the anterior face of the leg, and
irticularly that which corresponds to the fracture, uncovered. Thia

Apparatus is very restrictive, but after having used it for more than a
year I have given it up, for two reasons : first, because upon patients
with a fine and delicate skin, especially women, the diachylon causes
an erythema and unpleasant itchings; and secondly, because I have
twice seen an eschar produced on the heel, on the most prominent part
of the calcaneum.

The second, the envshping apparaiuses, are all those which hide
the fractured limb from the sight of the surgeon, and allow him to
examine it only by removing them in whole or in part. The Scultet
apparatus and the roller bandage are types of thia variety. The first
is much to be preferred, because the limb can be uncovered without
raising it, and consequently without giving it any movements which
might be painful or might disarrange the position of the fragments or
the work of consolidation. The trough, with straps, bag. and anterior
splint, belongs to the same category. If I have given it the prefer-
ence, it ia simply because, without spending loo much time, I can
unbuckle it, remove the splint and the bag, examine the limb, and
put everything in place again. But I repeat that if you are willing
to give it a little more time, the indication ia met aa well with the
Scultet or any other apparatus, as with that which I now use upoa
otii two patients.

]

FHA0TDBS3 OF THE LIMBS.

H 88

^m I have already told you that in about three weeks I sliall change

^f the apparatus, and subatitute an immovable roOer bandage, made with

a very concentrated solution of silicate of potash. Why this change?

It is certainly not that the consolidation may take place more regularly

or rapidly. Yon know what are the anatomo-phyaiological pheoo-

Imena which accothpany the formation of the calluB; you are acquainted
with the first period, that which is characterized by the eS'usion of
blood and plastic lymph about and between the fragments, that which
almost always, passing beyond the simple needs of repair, ^ives dS,
clinically, the inflammatory phase. You know the second period,
that which begins between the eighth and thirteenth days, and during
which the plastic matter, and perhaps the blood, are transformed into
a cellulo-fibrous substance about the fragments and the periosteum.
Finally, you know the third period which, beginning from the twelfth
to the fifteenth day, and continuing until the end of consolidation, is
characterized by the deposit of phosphate of lime and the formation
of bone corpuscles in the fibro- cartilaginous substance. Well, these
phenomena go on independently of our apparatuses ; we apply the
latter that the former may follow one another while the limb is fixed
in a good position, and that the callus may be as little of a deformity
as possible. If we should put on no apparatus, the consolidation
would, none the less, take place, provided that the limb was kept
nearly immovable, but it would be irregular.

If then we have recourse afterwards to an immovable bandage, it is
not to accelerate nor to regulate the callus ; in this respect the trough,
continued until the forty-fifth day, the Scultet's apparatus, if we had
used it, would give exactly the same results. We have no other in-
tention in thus modifying the treatment than to make the patient a
little more comfortable. You have often heard me ask patients with
broken iega a day or two after the application of an immovable appa-
ratus if they felt more or less comfortable than with the one that had
been first applied, and you have heard almost all of them reply that
they felt easier because it was lighter, and because the limb, especially
the foot, being better immobilized, they can turn and move a little in
the bed without causing any pain. It is then because the immovable
apparatus is more convenient and more agreeable to the patients that
we use it. As for any preference for the silicate of potash, it is not
absolute, and nothing would prevent us from using dextrine, simple
plaster, or plaster mixed with gelatine, or starch upon linen or paper.
It is quite indiftisrent. The important thing is to know how to well

I utilize these different substances.
A few years ago I used a good deal, and even now sometimes use
plaster or dextrine, which I applied in the following way : —
With the plaster we first make a clear paste by mixing it with water,
and then roll a dry band about the limb, previously covered with a
thick layer of cotton, while the leg is held by three assistants, two of
whom make extension and counter-extension, and the third supports
it at the point of fracture. I then roll a band of coarse tarlatan about
the limb, beginning at the foot, soaking it in and covering it, as I ad-
K vance, with the clear plaster paate placed in a basin under the leg. I

FBACTUHE8 OF THB LEO,

y^pply the plasier thus in three superposed layers of tarlatan so as to>
P'Jiave a sufficient thickness,

I much prefer this method to that of first applying the plaster to
ordinary band and then rolling it about the limb.

Dextrine is applied aa follows : it is not easy to dissolve this sub-
stance rapidly in water, and it would require too much time to make
a homogeaeous glue. In order to obtain it immediately we first mix
the dextrine with alcohol, which does not dissolve it, but which gives
it the appearance of a fine moist sand, then we slowly add hot water.
Aa the water has a great affinity for the alcohol, it penetrates into all
the interstices and dissolves the dextrine at once. The alcohol has
the additional advantage of making the solution dry more rapidly.

When the solution is brought to the consistency of a thick syrup,
a bandage ia unrolled and rolled up again in it so as to be thoroughly-'
impregnated with it. The bands thus prepared may he kept for somai
time. i

^The limb ia covered with a layer of cotton kept in place by a drvi
^nd over which the dextrinated one is applied. When this appli-f
cation ia ended, a little of the solution is spread over the outside toi
fasten the edges down. Bottles of hot water are placed about the
leg to hasten the drying, and yet, notwithstanding that, it does not!
become perfectly solid in less than forty-eight hours.

That is the disadvantage of dextrine : plaster dries too quickly,
dextrine too slowly. We possess now an intermediate substance, of
which I have spoken — the silicate of potash, The prepared aolution
is kept for sale. It is obtained by heating to red heat a mixture of
one part of powdered quartz with four parts of carbonate of potash.
The substance thus obtained is dissolved in water, and. evaporated to
the consistency of a thick ayrup.

It is applied exactly like dextrine, and has the advantage of drying-
much more rapidly, but the impure article which we sometimeH'
receive dries quite as slowly. At present I use the silicate because
it is good, but you would see me return to the dextrine in case I
found that the silicate furnished by the administration did not dry
rapidly enough.

You might also use plaster with the addition of gelatine, in the pro*
portion of two parts in a thousand of water, as recommended by-
Prof. Richet. The mixture, which is quite convenient, has, like the
ailicate of potash, the advantage of drying less rapidly than ordinary
plaster, and more rapidly than dextrine.

When you wrap the band soaked in a solidifying mixture abonft
the limb, it is necessary : 1st. To have the limb supported above and'
below the fracture by two aids, who will make extension and counter*
extension; 2d. To make sure that displacement is not produced, alt
accident which ia not probable, since we have reached a period in,,
which the consolidation is sufficiently advanced to prevent the frag-
ments from separating with so much ease ; 3d. To see that the foot {»■
L|» placed that a line drawn from the centre of the inner border of
Hthe first metatarsal bone to the inner border of the patella, is parallel'
' Ij tbe Bxia of the leg ; 4Lh. To surround the limb with a layer

m 90

H COtt(

r 6tb.

FBACTURBa OF THE L1MB3,

cotton, ao as to protect it from too much pressure upon certain points;
6th, To tighten it only moderately; tbe effects of too great constriction
would undoubtedly not be ao bad as during the first period of tbe
fracture, but yet this excess of constriction might cause pain antl
oblige the surgeon to remove the apparatus the next day or the day
after. Of course it ought to be examined after it has become dry, to
see if it threatens to cauae excoriation or gangrene of the skin at any
point, and to prevent this eomplication, either by putting some more
cotton between that pan of the akin and the apparatus, or by cutting
away the offending part. These precautions are especially necessary
in persons, such as women and children, whose skin is thin and easily
irritated or broken.

LEOrUBE Xll.

FRACTURES OF THE LEQ— Contihdkd.

Fraelorcs of the leg in tlio lower tlilrd, continued — " V" tracturaa witli iiaplaoBment
vrhioh lEi reiinaililii, but difficult to maintiiiu reduced, and fr&oturea with irreda-
ciUo displflOBDieot (3d and 4lh clinical varieties)— Fractures witli incomplete
perfaratiuu of tlie skin (5th cliuiual Tftrietj).

Gentlemen.: I. At No. 2fi, Ward Sainte-Vierge, is a man 35
years old, of habitual good health, who was brought to us ten days
ago with fracture of the lower third of the right leg, caused by a fall
down a staircase, but which still seems to have been indirect.

I shall not occupy your time with the qa&stion of diagnosis. As
in the other cases of which I have had occasion to speak, the diag-
nosis was easy; inability to walk, pain, swelling during the first few
days, mobility, crepitation, left us no doubt of the existence of a frac-
ture of the two bones.

I showed you, from the first, that there was an angular displacement,
for the leg described a curve the concavity of which was directed
upwards, and a rotatory displacement, for the foot rested on its outer
portion, and had turned outwards with the lower fragment. I told
you that we bad easily corrected these two displacements. But in
addition we had the most common variety of transverse displacement,
that in which the upper fragment projects in front. You were able
to fee! the first day, when as yet there was no swelling, that this pro-
jection of the upper fragment, instead of terminating in a sharp point
corresponding to the crest of the tibia, as is the casein oblique fractures,
had its point placed upon the antero-internal face, and at tbe extremity
of two lines of equal length, ao that the edge of the upper fragment
had the form of a projecting V.

I reduced this displacement, as I did the other two, the first day b^y

FBACTUBBS OF THE LEG. 91

the classical manrauvre of reiiuction, then placed the limb in a wire
trough, an(] completed tha dresaitig with the bag, the aaterior BpHot,
and the straps with which you are already acquainted. But when I
examined the leg the following morning, I found, that, although the
angular and rotatory displacementa were not reproduced, the trans-
verse one had reappeared, and that the point of the projecting V
exerted quite a strong pressure upon the under surface of tha skin.
I reduced it again, and then, replacing the limb in the trough without
completing the apparatus, I observed what took place. We saw the
upper fragment resume almost immediately its vicious position and
project under the skin. Again reducing it, I tried to maintain the
reduction by means of a layer of cotton and two longitudinal gradu-
ated compresses, which I placed along the whole length of the upper
fragment from two finger- breadths above the point of the V, so as not
to make compression over the point itself. My intention was to dis-
tribute a moderate compression all along tiie upper fragment. Above
the graduated compress I placed the bag and anterior splint, which I
bound down with three straps about the upper fragment, and one
about the lower one. The foot was also fastened to the sole of the
trough with a band.

The next morning, by slipping my finger underneath, I felt thai
the point did not again project, and thence inferred that the displace-
ment had not been reproduced.

But the following morning it was not the same. The projection
had again become very notable. I again reduced it, and renewed the
compression all along the upper fragment by means of a triple grad-
uated compress and a layer of cotton.

The apparatus has now been five days in place, and the diaplace-
inent has not reappeared ; I therefore hope that it will remain reduced.
Of course, if it sliould reappear after a few days, I should again re-

Lduce it, and try to make a more efScacious compression along the

b upper Fragment.

r Two peculiarities here require attention : Ist, the V-shape of the
upper fragment; 2d, the difficulty of maintaining the reduction.

l3t. The V shape of the upper fragment has not in itself a very
great importance. But it has the advantage of indicating some
anatomo-pathological details of a certain clinical value, which with-

Lout it we could not suspect.

I I have made several autopsies of fractures of this kind while they

\ were quite recent, and found that when the upper fragment showed
this projecting V in front, its posterior surface was very irregularly
divided, and showed also two lines of fracture forming a re entrant
V with its point directed upwards, that at the same time the inferior
fragment presented in front a hollow V corresponding to the project-
ing one of the upper fragment, and on the posterior surface a point
fitting into the re-entrant V of this latter. Hence an irregularity in
the main line of fracture, which cannot be included in the anatomo-
pathological divisions, heretofore admitted, of transverse and oblique
fractures, and which was better described by Gerdy under the name
of toothed or pointed fractures. It is a curious and inexplicable thing,

e
e

FBACTtTBEa OF THE LIMBS.

this irregular and complex direction of the line of fracture in a bone

voluminous as the tibia, and under the influence of the indirect

causes which I have had occasion to explain (page 80). But this is

not aU : when the fragments present this alternation of large V-shaped

points and indentations, we find also the marrow considerably bruiat
and in the lower fragment a fissure which, starling from the point of
the re-entrant V, winds in a spiral about the inner face of the tibia,
then the posterior face to the tibio-tarsal articulation, traverses th^^

FBACTUBE3 Of THE LEG.

articulation near ita posterior border, and rises again along the posj
terior face, tbus oircumacribing upon it a lamellary fragment.

The first time I saw this long fissuml prolongatioo, causing the seat
of the fracture to coramimicate with the ankle-joint (it was in 1854,
at the Hopital Cochin), I supposed it to be a very uncommon lesion,
and althoagh I had occasion to see successively two examples (Figs.
5, 6, 7, 8, y), which were described in a note' and in the thesis of Dr.
Bourcy,' I could not believe that a fact so curious could if often met
with, have escaped the investigation of surgeons so completely that
) no author, up to that time, should have spoken of it

But soon new observations collected by ray colleagues, especially^
my MM, Chassaignac, Houel, and H. Larrey, and myself, showed us thatj
pdireet fractures of the lower third of the leg very often presented*
ihis irregular main line in form of a V, and the long accessory line irffl
1 of a fissure, extending to the articulation of the foot, and thai'^
consequently it was necessary to admit three principal anatomical
varieties of fracture of the leg in the lower third, corresponding to
as many clinical varieties: toothed fracture {transverse of the old
authors), oblique fracture, and V fracture.

I see among our conlemporariea a certain tendency to suppress this
latter denomination, and to replace it by that of apiroid fracture given
by Gerdy to some which, though analogous, differed in many respects,

OosaeHn, Le^on olinique faite it rHflpilal Cochin sur les Fiaclnrea en V dn Tibia, M
'.. den Hapitanx,1855, p. 218. "

[tBoaroj, Tb&aesde Paria, 23 June, 185G.

94 FRACTUBKS OF THE LIMBS.

and wliich lie had (lescribed for the thigh. For my part, I reject the
name spiroid, because it indicates only the secondary lesion, the
fissure which cannot be discovered in the living patient by physical
signs, while the denomination V/raclure is based upon the direction
of the principal line of the fracture, and indicates a distinction which
can be recognized, at least in part, through the skin. We should,
however, remember that this name indicates not only a particular form
of the principal line of fracture, but also a spiroid fiasural prolonga-
tion extending to the articulation. It is unfortunate that a single
word cannot express these two facts.

Before going any farther, let us see what relation exists between
the V shape and the liasure on the one side, and the Y shape and
bruising of the marrow, which I have already mentioned, on the other.
I believe that I gave, in my earlier publications upon this subject,^
the only possible explanation, in saying that, in consequence of the
absolutely inexplicable direction of the principal line of fracture, the
upper fragment exerted, at the very moment of the accident, a pres-
sure like that of a wedge upon the lower fragment, causing it to
burst inlo pieces, and that this same pressure crushed the marrow.
I thus extended to fractures of the lower third of the leg, the study
of the results of the reciprocal pressure of the fragments immediately
after the production of the main line of the fracture, a study which,
in other fractures, and notably in those of the lower extremity of the
radius and those of the neck of the femur, has given as penetrating
fractures.

Let us now return to our patient: he has a V fracture, that is to say,
a fracture with crushing of the marrow and fissural prolongation
towards the articulation. N"ow these latter lesions, and even the form
of the lower fragment, are not indicated by physical signs, but only
hy the projection of the upper fragment which we feel through the
skin when the swelling has not yet become very great or when it has
sufficiently diminished, and by our ana tomo- pathological studies
which have taught us (the pieces in the Mus^e Dupuytren prove it)
that, in those cases where the upper fragment presented this form, the
other lesions mentioned were not lacking. What conclusions should
we draw from these notions with reference to the ultimate course and
prognosis of the fracture? The patient will have a tibio-tarsal
arthritis, and this arthritis will leave behind it for a longer or shorter
time a semi- anchylosis or stiffness. Unquestionably tliis is not a
coincidence which belongs exclusively to V fractures, for we often
see the articulation inflame by simple proximity, but that which is
possible in other cases is almost inevitable in those where the fracture
extends to the articulation. As to the subsequent stiffness and difB-
culty in walking which it occasious, I should fear its long duration if
the patient was a little older or subject to rheumatism or gout, for, as
I have often told you, the daration of this painful stiffness and loss

J35 ; aad Bulletin da la

FRACTURKS OF THE LEG. 95^

l^^a ail

function following sponfaneoua arthritis and long immobility

Hepends upon the age. The older the patient, the longer the duration.

We draw from the above-mentioned notions this other conclaaion,

that the patient is a little mure exposed than others to suppurating

Wteo- myelitis.

Upon this point I was led into an error by a singular chance at tha.
leginning of my labours upon this subject. My first two patienti
affected with V fracture had, the one a compound fracture, the otbei
a simple one, and both died of purulent infection following suppura<
tive osteo- myelitis. I did not infer that alt those who should have V
R-acturea without communicating wounds would have suppurative
Mteo- myelitis, but I concluded that they were exposed to it in a certaii
"measure.

Since then I, as well as other.'*, have often seen simple fractures
this kind which were not complicated either by suppuration of th«
l^^^marrow or by purulent infection.

^^L I say to you then, our patient, because he has a Y fracture, and

^^nrith it a crushing of the marrow, is more predisposed thau others to

^^BD osieo- myelitis. But as there is no external wound, the suppura-

^^KjoD of which might extend to the fracture, it is more than probable

^^Bhat he will escape this dangerous complication and will get well.

^^B 2d. I now come to this displacement, which is reducible and difE-

^^^onlt to keep reduced. To what is it due? To this, that at tha

' moment of the accident and of the wedge-like action by vertical

pressure and rotation of the upper fragment upon the lower one,

extensive ruptures were caused about the first. Not only was the

periosteum divided, hut the museies were extensively torn at the

moment of the great muscular e&brt during which the bone was

broken and acted like a wedge upon the lower fragment. Freed from

all its connections, this upper fragment is easily drawn upwards by

the action of the quadriceps femoris, and it is only by means of a

considerable and constant pressure that we can keep it in place.

But what disadvantage would there be if we paid no attention to
this displacement and did not correct it? First, its point might per-
forate the akin immediately or after the formation of a small eschar
by its pressure, which would change the simple fracture into a com-

■|}0und one, and would expose the patient to the tedium and dangers ^^m
bf a consolidation after suppuration. Secondly, supposing that thiil^^^|
pnfonunate complication should be avoided, the patient would get^^H
well more slowly because the callus would be made by only a part of^^H
the contour of the fragments, that by which they touched one another,
and all the materials poured out by the rest of the contour or between
the fragments would not be ulilized. Finally, the callus would be
irregular in two ways, because an abnormal projection would persist
indefinitely, and because the persistence of the transverse displace-
ment would cause longitudinal displacement and a permanent short-
ening of the leg. _
I know that in such cases it is more important to attend to th»J
function than to the shape, and that notwithstanding the irregularU'T
ties of which X speak, the limb would recover its usefulness in wal'

I 96

FRACTURES OF THE LIMB

ig and standing. Nevertbelesa, patients, especiallj' women, are

Iwaya diasatisfJed with being deformed, and if we do not wish to be

accused of negligence or incapacity, we should make every effort to

obtain a cure of fracture of the leg with a callus as little irregular as

possible.

What means are at our disposal to correct this tendency to dis-
placement ? It 13 evident that ordinary restrictioD by the apparatuses
with which yon are acquainted is insuffieieot, and that it is necessary
to add something to them,

I told you what I did for our patient: compression all along the
upper fragment except at the point where it might cause an eschar.
Take care not to yield to the idea which at first presents itself of
compressing the extremity itself of this displaced fragment by means
of a cushion and a small splint. If you should do that you would
run great risk of causing mortification. For the skin would be com-
pressed at this point between the fragment which tends constantly to
be drawn outwards, and the accessory apparatus which would press
it backwards. It would be better, as I said, to distribute the com-
pression above the point of the V, than to concentrate it at that poinL
It is, furthermore, necessary to tighten it a little more than usual, and
relax it if the patient sufters. You remember that the limb has been
attentively watched, and that I have renewed the reduction whenever
the displacement has been reproduced, I do not advise you to have
recourse in cases of this kind to the Scnltet apparatus, because in
order to make compression efficaciously along the whole length of the
upper fragment it is well that the limb should rest upon a hard plane,
and because it is indispensable to examine the fracture once or twice
every day, and to repeat the reduction if necessary. Now it is not
easy to make up your mind to open so often a complicated Scult«t
dressing; it is much easier with the trough, or Malgaigiie's box, or
Boux's polydactylio box. You understand, also, how necessary it is
in such cases not to withdraw the limb from observation by envelop-
ing it in an immovable bandage. The fracture should be constantly
examined until at least the 25th day, that is to say, until the time
when consolidation is so far advanced that, even if it should seem
necessary, reduction could no longer he made.

Compression, such as you see me apply, is not the only means
which we possess. "We might use in this case Malgaigne's point,
which consists of a metal rod attached to a steel hoop through which
it can be raised and lowered by means of a screw.

I have twice used Malgaigne''s point for fractures similar to thia
one. In one of them the final result was very good, but was obtained
at the price of quite severe pain. In the second, the patient com-
plained of violent pains which obliged him constantly to loosen the
screw, and finally he had an erysipelas, of which he got well, but
which caused the treatment to be suspended. In short, I find that
compression is preferable because it is less painful and can produce
the desired result without any lesion of the skin, and I should use
Malgaigne's method only in oase this compression did not prevent
" splaoement.

FRACTDRBa OP THE LEG,

971

, I advise you also to accustom yourselves to do witbout thes

_)eoial apparatuses. The fracturea for which they can be used ar^

^ot frequent, and whea they are met with, these apparatuses are notl

llways at hand or are in bad condition, as are always those instru*"

Fig. 10,

[jnents of which we do not make daily use. Keep them, if you choose,
for hospital practice and the large cities, but in ordinary practice use
the means which are always at hand, such as cotton wadding, oakum
if you have no cotton, or pieces of linen folded into long and narroflT'
com presses.

II. Fracture with irreducible Iransmrae displacemfil. — At No. 45,
there is another variety of frncture in the lower third of the left leg,,
which we have had under observation for a fortnight. It is in a rather
young and vigorous man who fell while running, and in whom we
laave no reason to believe in the intervention of a direct

Since the first day we have recognized the projection,of the uppeiT:
fragment and its V shape; but it was in vain that I tried to make it
disappear by executing the manoeuvres of extension, counter-extea'
sion, and coaptation ; I did not succeed ; I applied poultices for three.
days, gave opium, and left the limb untouched, hoping that perhaps
reduction was prevented by spasmodic muscular contraction, and that
this contraction would disappear with time. The fourth, fifth, and
sixth days I failed as on the first. I succeeded iu diminishing the
projection by means of the compression mentioned in the preceding
case, without causing an eschar; but I did not get complete reduction,
and I am obliged to recognize that I am in the presence of one of
those irreducible displacements which our predecessors did not de*
scribe. For in all the books which preceded Malgaigne's, reduction
of fractures is spoken of as a very simple thing, which is always easy
and never meets with obstacles. Now the case before us, the ex-
amples of which, fortunately, are not very frequent, shows you that
it ia not always so.

Can we at least explain this irreducibility? I might be permitted
to attribute it to muscular action which, the transverse displacement
once produced, had caused the over riding, and had been too strung
lo yield to the attempts at reduction. But it ia very rarely and with
7

98 FBACTITRES OF THE LIMBS,

much difficulty that the upper fragment entirely abandons the lower
one. On account of the breadth of the bone and the irregularity of
the fracture, the fragments always touch at some points, and mus-
cular action does not produce so ranch overlapping that our efforts at
extension cannot overcome it. Moreover, experience has shown ua
that in fractures of the leg longitudinal displacement, which is always
the result of muscular contraction, can most often be easily corrected.

In these exceptional cases where reduction cannot be obtained, I
think it ought to be attributed to some obstacle offered either by a
strip of muscle or by a splinter or piece of bone, which has slipped
into the place of the upper fragment.

We can never demonstrate materially either in our present patient
or in those of the same kind which we meet from time to time, the
interposition of a foreign body between the fragments; but as autop-
sies of recent fractures have demonstrated it sometimes, we have a
right to believe in its existence in irreducible cases. I have in my
collection a specimen which came from a woman in the Hopital de la
Piti^p who had a compound fracture, the upper fragment of which I
was unable to bring into place. This was due to a large muscular
bundle of the tibialis posticus which had caught upon the end of the
lower fragment and occupied the place of the upper one.

I have often met also with splinters of bone placed crosswise in the
inter- fragmentary space, and I have found them especially in V frac-
tures, For the result of the splitting and rotating action of the upper
fragment upon the lower is sometimes that one of the sides of the
lower or hollow V breaks, and the fragment, drawn by the muscular
fibres attached to it, or in consequence of an impulsion comraunioated
to it by the lower fragment, or of some outside pressure, leans towards
the inter-fra^mentary space and is caught in it so as to oppose reduc-
tion. What happens with one of the sides of the hollow Y may also
happen with some detached point or with several, and thus, instead of
one, we have several obstacles to reduction,

I repeat that I do not know what is the obstacle in this case ; but I
presume, from what I have seen in the cadaver, and from the full V
shape of the upper fragment, that reduction is prevented by a cause
of this kind, and that it would be impossible to reduce it completely.

We shall then expect to see this patient get well slowly and with
a deformed callus, which will, however, in no way affect the functions
of the limb. I shall forewarn the patient of this result.

Let us also meet the indication of pushing back this fragment as
far as possible towards its proper place, so as to avoid an eschar over
the point, and render the deformity as slight as possible.

For thai purpose we apply graduated compresses all along the upper
fragment. This would be a suitable case for Malgaigne's point^ if we
preferred it. But although this eminent surgeon claimed that his ap-
paratus was almost infallible, you may he sure, that in a case of this
kind, it would not have succeeded in removing thedeformiiy entirely.

In any case, remember this fact, that although our classical authors

' MBlgHiBne, TrsiU de% Uaeiatet el lusatiouB, F&riB, 184T'1£54.

FBACTUBG3 OV THE LEG,

have represented fractures of the leg as always susceptible of redue-,
tion, it must be admitted that some are irreducible, and that the oon-j
seeutiva deformities are due to the circumstances of the fracture and,)
not to the carelessness of the surgeons. I treated this subject fully iu j
1869.'

III. Fracture of the lower third of the leg with transverse displacement . I
and projection foncards of the lower fragment.— I do not wish, gentle-, '
men, to describe fully all the varieties of fracture of the leg ; but let: 1
me teli you, in passing, that if displacement of the upper fragment ii
the one which is the most often observed, you will also see in sorae^J
rarer cases transverse displacement of the lower fragment forwards.

We have an example in the woman who occupies No. 10. At the.l
time of her admission there was a notable projection of the lower i I
fragment which I was able to reduce and keep reduced.

But you will also meet with patients in whom reduction and retea-..
tion are difficult. That may be explained in the same way as the i
irfeducibillty of the upper fragment, by a peculiar interlocking, or;l
by the interposition of a splinter or piece of muscle. But we n
also attribute it in part to the action of the gastrocnemius and soleus, I
which, drawing the calcaneum and lower fragment upv/ards, keep the
broken end of the latter in front of the upper fragment.

I do not know what causes this kind of displacement; in any c
it does not coincide with a Y fracture, and ia found in certain toothed
and oblique ones. The prognosis and treatment present no peculiarity.

IV. Fracture with very prominmil angular displacement forwanis. —
Notice also the patient in No. 26, in whom, on the day of his admis-
sion, we found a fracture in the lower third of the two bones of the
left leg with a very prominent angular projection in front {angular,
displacement). Lateral angular projection is not very rare, it ia easily
corrected, and rarely reproduced. But the stime ia not true of angular
displacement with prominence in front; it is easily corrected, but h
a great tendency to reappear, and the surgeon should struggle against. |
this tendency so long as the callus ia not sufficiently strong to oppose, .
its reproduction.

I make the reduction in this case very easily every morning, and !
compress with a cushion and anterior splint as well aa possible. The
next morning I find a little of the projection which I had e&aced so
well the day before, and I am obliged to make a new reduction.

This is another of those cases in which it is necessary to examine, I
the limb every day, and to correct the deformity as often as possi' '
Be careful in such circumstances not to apply the immovable appa- ,
ratus too soon, for if the callus hns not already acquired a certain i
solidity when you inclose the limb, the angular projection will be I
reproduced little by little under the apparatus without your perceiving
it, and when you remove the bandage you will find the leg solid but
very irregular, with an angular callus which will shorten it very much,
and compel the patient to walk upon his toes and to wear a shoe with
a very high hecL

100 FRACTURES OF THE LIMBS.

I shall undoubtedly Dot npply tlie silicated apparatus before the
thirtieth day, and even if I tben find marked mobility I shall not
apply it at all, and shall continue to tiae the ordinary apparatus, exam-
'niug it often, until the end of the treatment.

I have not thus far spoken of section of the tendo Achillia as part
of the treatment of fractures of the leg with displacement difficult to
correct, hecauae this operation, proposed long ago by Laugier, seems
to me useless in the transverse displacements to which I have called
your attention. For of two things, one: either thei?e displacements
can be reduced and maintained by the aid of the measures which I
have mentioned, in which case tenotomy would only add to the con-
secutive muscular weakness of the limb; or the displacement cannot
he corrected, which is due, as I have told you, rather to certain pecu-
liarities of the fracture than to contraction of the gastrocnemius ; ten-
otomy, therefore, would be useless.

But in angular displacements forward which are so easily reproduced,
it is allowable to think that the contraction of this muscle baa a great
influence, and that consequently division of the tendo Achillis by
temporarily suppressing the cause would also suppress the e&ect. But
I can support hy no personal experience the advantages of this opera-
tion, for I have had no occasion to perform it, and the examples pub-
lished by Laugier, who, according to Malgaigne, introduced this modi-
fication of the treatment, and by M.Meynierd'Ornana, are uot numerous
enough to bring conviction,

In a word, the procedure is not generalized in practice; is it because
it has not been considered good, or because the particular class of cases
to which it is appropriate, the one which now occupies oa, has not
been clearly indicated? I do not know; but it is for this reason, and
also because I expect to succeed without it, that I have not had re-
course to it, On one occasion, however, I keenly regretted not having
employed it, for, notwithstanding all my care, my patient got well
with an infirmity and ashortening which tenotomy would undoubtedly
have avoided.

V; Fracture willt engagement of the point of the fragment in the thick-
ness of the skin. — Finally, gentlemen, I wish you to notice, in passing,
the patient in No._7, who presents a singular fracture of the tibia.

The point of the upper fragment is implanted in front in the under
portion of the skin, that is to say, has spitted it without traveraing its
entire thickness. This ea.se establishes the transition between fractures
without wound and fractures with wound. You saw that I tried at
once to withdraw the bony point from the skin, and in this case I
succeeded quite easily with my hands alone and by the ordinary
mauoauvres of reduction.

It is not always so, and once I bad to draw the skin downwards
with a double hook implanted on the aides of the point.

In another case all my efforts to disengage the point were unsuc-
eesaful, I then treated the fracture without occupying myself any
further with this incident, and bad the satisfaction of seeing that little
by little the depression of the skin diminished; at the end of the
treatment it was no longer adherent, the point had been reduced s|)oc-

i OP THE LOWER THIRD OF THE LE

laneously. Remember this pecnliarity if ever yon have to trent a cnsQ-J
F this kind. Try to disengage the point, and if you do not sucoeeclj
treat your patient as for an ordinary fracture.

LECTURE XI IT.

COUPODND FKACTORES OF THE LOWER THIRD OF THE LEG.

nil iFoiiiid. DiagnosiB oompleted by tiie fiovr of blood and drops of oiL
Ib tBrniimttion without flnpporntion. Aftar mild supporating oateitii
eorosia. After putrid aud infauling ostfiO-myelllia. ImportMiea of ooolasiaanj
Methods of praotii^iag it. [mbricated. strips of .iiachflon plaster. Bauda dippa2f
In ooUodl'iu. II. Large nouud. Suppuration more diffianlt to avoid.

GentlewkN : We visited ihia morning, at No. 41, a miin abou

Bears old, who broke his left leg by a fall upon the ice. When he wa? I

Kicked up his stocking was found to be wet with blood; and after wej

I undressed him, and cut off this stocking, we found at the anterioi^

jortion of the leg, near the junction of the lower and middle thirdtL

I wound nearly half an. inch long, through which a bony point pTofl

joted slightly. Blood, mixed with drops of oil, flowed from th^

Itound. There is also an abborlnal mobility which leaves no doubul

B to the existence of a fracture of both bones. But this fracture ift]

bmplioated by, a small wound with issue of the upper fragment.

This patient reminds you of two others whom we have seen during
the year, and in whom you did not have the opportunity of seeing
the projection of the upper fragment. In one of them the reduction

I had been made by the interne on duty the evening before our first
jfisit, In the other the dressing was also made in the evening. The
Interne had not found the bone projecting, but as he saw a considera-
ble quantity of blood escaping, and as by passing a probe carefully ,
glto the wound, he felt the denuded extremity of the fragment, he j
»ad convinced, and I shared the conviction, that the wound c
Bleated with the fracture. But had this wound been made, like th9,J
two preceding ones, from within outwards by the fragment itself, or, \
OB the contrary, from without inwards by some external vulnerant
body? There we had to deal only with probabilities, and it is so in
moat cases of this kind; certainty almost never exists. The proba-
bility that the bone was the vulnerant body is based upon the nap- '
rowness of the wound, and the absence of a severe contusion, such as^i
would have been produced by a blow, titill, this question is nut ofjj
apital importance. The wound was not quite half an inch lung, it
dges were not bruised, and its condition was favourable for immediate
Soion, which ia the essential point. Let us here recall the case of
mother patient.

102 FRACTDRE3 OF THE LIMBS,

Towflrd tlie end of last year I culled your attention to a patient,
who, with a fracture, probably toothed, at the junction of the middle
and lower thirds of the leg, had on the anterior and outer portion of
the limb a wound through which no one had seen a fragment project,
and through which a probe, passed with all the precautions indicated
in such a ease, had not reached the fragments or the intervals between
them. Was the wound in communication with the fracture, or was
it independent ? We had two reasons to think that it comraanicated :
the first was that from the information furnished ua,and from the quan-
tity of blood that had soaked into the dressing during the fifteen hours
that had elapsed between the patient's admission to the hospital and
our visit, we saw that the wound, although small, had bled n great
deal, but without the interrupted spirt and the bright colour which
characterize arterial hemorrhage. Wounds occupying the soft parts
do not bleed bo freely and for ao long a time, unless an artery is
wounded, and that, I repent, is not the case here. On the other hand,
when the wounds communicate with a fracture the fragments always
furnish a large quantity of blood which cornea from the capillaries of
the periosteum, from the bone itself, from the marrow, and from the
nutrient arteries. It is this abundance of blood which causes the
effusions and infiltrations of the first days, the e.itensive ecchymoses
which you see increase during the first two or three weeks, and
which disappear so slowly.

The second reason for believing in the communication was the
presence of drops of oil in the blood which flowed the first day, I
admit that this is not a pathognomonic sign ; I know, and I should
warn you that the fat of the subcutaneous cellular tissue can supply
drops of oil to the blood of a recent wound interesting only the soft
parts; but these drops appear only in small quantity and for a short
lime, especially when the wound is small. On the other baud, the
marrow of the bone, the fat of wbieh is more liquid, furnishes more
and for a longer time when it has been torn. That is why the ap-
pearance of oily drops in the blood of small wounds coinciding with
a fracture, ten, twelve, or fifteen hours afier the accident, is a strong
presumption in favor of the opinion that the fracture is compound,
that the wound communicates with it. When the flow of blood is
moderate, and the oily drops are not found, we have to remain in
doubt, and incline towards the opinion which involves the treatment
most favourable to the patient. Admit, in such a case, communica-
tion, rather than not. There is no disadvantage, if the wound ia
independent, in treating it as if it communicated, and there are very
great ones iu treating it as independent if by chance it commu-
nicates.

But to return to our patient : 1 reduced the fracture very easily,
and was able to replace the point of the upper fragment which is on
the anterior border, and does not indicate a V fracture. Here, then,
is a patient with a nearly transverse wound one-quarter of an inch
long, about which the skin is probably loosened tor a certain dis-
tance, and which commuiucates with the seat of the fracture, a sort
I of accidental cavity limited by the fragments, and filled with liquid

FRACTUBE8 OF TBE LOWER THIRD OF THE LEG. 103 \

Hoc

pel
ost

aiii5 coagulated blood, Wbat would happen if we should leave the
wound in the state in which it now is, and occupy ourselves only
with the ordinary treatment of the fracture? One of the four fol-
lowing things :^ —

Either the wound, being narrow and but slightly bruised, would
beal promptly and without suppuration. In three or four days the
frneture would be no longer exposed, and would advance to a cure
like any other simple fracture.

Or the wound would not heal by first intention; it would suppu-
rate, but the suppuration would be limited to its edges and would
not extend inwards to the seat of the fracture, the deeper layers of
the soft parts having united immediately and opposed a barrier to
the extension of the suppuration towards the deep parts. In tliia
case the fracture would also heal like a simple one.

Or the suppurative inBammation starting from the wound, imnae-
diate union of which had not taken place, would extend further and
ferther towards the seat of the fracture, that is to say, to the bones,,,]
*" id especially the tiliia, whose greater size renders its suppuratiott:
.ore important and more dangerous; the suppurative inflammaiiun
would invade, in all probability, all the constituent parts of the bunej
periosteum, compact substance, and medullary substance. In a word»,
osteitis would supervene, or rather — uncomplicated, mild, suppurat-
ing osteo-myelitis of acute or subacute form ; we should have as locaj

mptoms of this disease: —

1st. During the first few days a dift'iise and painful swelling of tha
,^imb, and the development of a more or less intense fever which we
'lave called, since Dupuytren,' traumatic /ever.

2d. A little later, and for a long time, an abundant suppuration
following subcutaneous or intermuscular diffuse phlegmons, a ne-
crosis keeping up fistulas until elimination of the mortified parts has
taken place, and finally cure with one of those more or less consid-
erable hyperostoses, of which I shall have ocoaaion to show yoij
examples.

Or finally, the suppurative inflammation extending to the bones
would there take on the form which I call putrid or infecting osteon
myelitis, which difters from the preceding one by two capital char-
acteristics: —

1st, By the formation of eschars and the putrid decomposition of

B blood upon the soft parts of the wound, and especially by the
;angrene and the decomposition of the medullary substance and the

itravasated blood in the medullary canal, and in all the canaliculi

hich have been opened by the solution of continuity.

"d. By the coincidence, with this putrid decomposition, c
ie fever during the first few days, with a pulse of 120 or laO, and'

. axillary temperature of 10i"°, headache, thirst, sometimes de-

■ium, and, later, purulent infection.

Do not forget, gentlemen, that by the very fact that a patient is'
pxposed to suppuration of the bone, he is exposed to this putrid and

' Dnpnjtren, Lagona orales, tome Ti.

I
I

104 FRACTURES OF THE LIMB3.

malignant variety of acute osteitis and the consequences I mentioned,
especially to dealb by purulent infection, which Happens more often
than death by iraumatio fever, the latter being really primitive
putrid infection, while the oiher is consecutive or secondary putrid
infection, and the hecticity, which sometimes occurs still later, may
be considered as a tertiary putrid or septic infection.

But perhaps you would aak me the following question: If this
man is threatened with an acute suppuration of the hones, have you
any reasons for hoping that this suppuration will take on the mild
rather than the malignant form, or for believing rather in the develop-
ment of the latter, and of one of the varieties of dangerous septi-
ceemia wbich you attribute to it ? I can reply only with presumptiona.

If the patient was in the country, if he was not in a hospital, if I
was sure that he was not given to drink, I would reply: Yes, his
ound, in itself, exposes him to acute suppurating osteo- myelitis, but
there are, in the circumstances mentioned, reasons for hoping that ihia
suppuration will nut take place, or that, if it does, it will remain simple
and mild, or, if you prefer, non-putrid and non-infecting. But, on
the one hand, the atmospherical conditions in which he now finds
himself, and on the other, his previous life in a great city, his exhaus-
tion by fatiguing labour, his alcoholic habits, his present position in a
ward charged with nosocomial emanations, are so many unfavourable
circumstances which predispose him to suppuration of the bone and
to the putrid and gangrenous form of this suppuration. It is true,
that this predisposition exists only in a certain measure, and I cannot
tell you just what that measure is. For above all these causes one
other is needed which is purely individual, and which is inherent to
the constitution and to its aptitudes. Multiple as are the causes of
which I have spoken, it may he, nevertheless, that the constitution
does not favour suppuration of the bone and especially putrid sup-
puration. On the other hand, moderate as may be all the occasional
causes, the constitution may be one of those which engender pus and
putridity easily, notwithstanding all that is done to prevent, and it ia
because we are in the most absolute ignorance upon these individual
aptitudes which annihilate or fortify the action of all the other causes,
that I cannot say what will happen. I tell you what is possible, but
I cannot tell you in what degree it is possible.

The only thing which I wish to fix in your minds is that a wound,
even a small one, which complicates a fracture of the leg, exposes it
to suppuration and all its possible consequences ; dangerous traumatic
fever, suppurative, acute osteo- myelitis, purulent inlection, hecticity,
or necrosis, and slow cure with a deformed and painful callus.

But there ia one circumstance which diminishes the gravity of the
prognosis in the case of our patient. All that I have just said ia
under the inexact supposition that we should not try to do anything
for the wound. But, on the contrary, we shall treat it with great care,
and I hope that our efforts will meet wiih success, and that we shall
prevent aujipuration of the bones and its consequences. I have the
more reason to expect this rtsuil because the wound is small, its edges
are not bi uiscd, and there are no eschars to be eliminated. Under sucb.

FftACTL'ESS OF THE LOWER THIRD OF THE LB

to hope for immeiJiate i

■i.freo.

poinHtiona I have every
I'ithcmt suppuration,
The meana by which to obtain it are very simple, and yet it is onl;
nthin the last twenty years that they have been well undi
brmulated, and applied.
The aurgeons of the seventeenth and eighteenth centuriea advist
'a true, that the wound should be closed by means of agglutinativi
■but they devoted themselves above all to the reduction of the frai
r^ture, ns Eoyer's article on compound fractures' will show you. They
thought little about the wound, they indicated neither the mode of
application nor the length of time during which the aggluti natives
should be kept on, and, furthermore, they possessed only insufficient
s which softened in contact with the blood and became loose the
£Tat or second day after their application, and did not keep the edges
_ 'together long enough to prevent suppnration. Consequently the aur-
i.jlreons of the beginning of the nineteenth century did not comprehend
the precept sufficiently to apply it vigorously. Led away by the idi
which ruled at that time about inflammation, they tried to moderata
it by various topical applications, hoping thereby to prevent it frona'
heeomiug suppurative. Poultices, leeches upon the injured limb,
systemic bleeding, diet, in a word tdl that constituted antiphlogislio
treatment, was recommended, and the dressing of the wound was
made of secondary importance, consisting in the application of a piece
of diachylon or court- pi aster, which met only temporarily and incora-,
pletely the main indication, that of keeping the edges of the solution ;|
of continuity together, and protecting them as long as possible from

IAontact with the air.
t It was still with the hope of moderating the inflammation that A.
pifrard, Breschet, and many others afber them, had recourse to con-
linoous irrigations of cold water, and Baudens to refrigeration by
nieans of ice. Undoubtedly they sometimes succeeded with these;
Bieana when the wound was a small one; but they often failed, while,
toii the contrary, with the dressings which we have at our disposal to-
day, success, that is to say, non-suppuration, is the rule, and failure the
exception.

To M, Chassaignac^ belong.s the merit of distinctly formulating this
^Hfiurgical point under the name of occluUml dressing. This dressing.
^■ISonsisted, when its author recommended it, of small strips of diachyloa '
^^Bverlapping and crossing one another over the wound, the edges of
^^nrhich had previously been brought as well together as possible. He^
^^^aced several layers, one over the other, so aa to form a sort of'
^^Bnirnss, and left it all in place for ten or twelve days. I

^^ft But the occludent dressing has been singularly improved by thefl
^Bne of collodion. With this substance we make an apparatus which ,
^^Bries rapidly and remains Brmly attached to the skin without becom- '
^^■ng soft or wet by contact with organic liquids. The pieces may '

^^^^* Boyar, tome iii., lat editlou, p. 68.

^^^L * ChaH^aigiiao. Des (Ip^rationa applicftblea a

^^H|lte« <le CaocDUrs pDai ta Cliaire d'Oplrstloiis et

^^M#iW*>f'>'i<^ *'t <lu Draiuase, tome i. p. 514.

and ^^^

-a^^H
om'^^l

106 FRACTURES OF THE LIMBS,

sily be left in pkce for the necessary time, six, eight, and even ten
day a. ' *

By its exact application and adhesion collodion gives a first and
very important result. It protects the wound and the rest of the
fracture from contact with the air, the presence of which leads so
easily to decomposition of the blood and exuded products, an altera-
tion which inevitably causes suppuration. It aatisfiea two other capital
conditions, that of keeping the edges aa exactly together as possible,
and that of immobiliaing them by preventing any slipping or folding
of the akin.

For we have to obtain permanent reunion as well as occlusion, in
order to reach the great result which we seek.

We have to choose between two methods of applying the collodion.

The first consists in cutting a certain number of strips of linen,
half an inch wide and from two to three inches long, and in dipping
each one successively in a mixture of collodion and castor oil, the so-
called elastic collodion, which is less irritating than the ordinary
collodion. The leg being well placed in the trough or fracture-box
where it is to remain, an assistant brings with two fingers the edgea
of the wound together, and while he holds them in contact the surgeon
applies the first collodionized strip. He places a second over the first
in the form of an X, then a third parallel to and covering about two-
thirds of the first, a fourth parallel to the second, and so on, so as to
cover the wound itself and about an inch of the surrounding parta
with a sort of collodionized cuirass. When the dressing is completed
the strips are very tightly applied, close the wound, and confine the
skin all around it.

The second method consists in covering a piece of goldbeater's
skin about an inch and a half in diameter with collodion, sticliing it
upon tbe wound, and placing a second over the first.

I have used both methods and prefer the first. The separate bands
are better than the goldbeater's skin, for the latter sometimes leaves a
gap which might favour the displacement of the edges of the wound,
and it compels the use of a larger quantity of collodion, which some-
times causes phlycteuEB.

I applied upon our patient the collodionized and imbricated strips of
linen, after having satisfied myself again that reunion had been well
made, and I completed the dressing with the anterior splint, cushion,
and straps, I placed him upon the mechanical bed, and I advised him,
even more strongly than usual, to avoid every kind of movement.
During the following days I shall examine the leg, press upon the
cuirass to see if this pressure causes a pain which might indicate in-
flammation, or if it causes the issue of a few drops of sanguinolent or
purulent serosily. If, as is very probable, I find neither pain nor
oozing, I shall leave the dressing in place for ten days; at the end of
that time I shall remove it, and I can tell you beforehand that the
little wound will be cicatrized, and that the fracture, transformed into
a simple one, will heal after the usual lapse of time. During the last
four years I have used this dressing a dozen times in cases where, aa

' FRACTDRSS OF THE LOWER THIRD OF THE LEG. 107']

in this one, the wound was not very much contused and was not half I
an inch loner, and in no case did suppuration of the bone ensue. J

Consider it then as certain that this mode of treatment is auperiorl
to any other, and relieves you from having to make use of antiphlo- |
giatics, continuous irrigation, and ice, the success of which is muchr ]
less probable.

While speaking of these recent small wounds which heal under the
Dccludent dressing, I wish to remind you of a patient whom you saw
a few months ago in our wards. He was a man 30 years old, who, in
consequence of a fall from some high pjuce, had a fracture with irre*.
ducible displacement. We made every elfort to reduce the fracture^J
but without success, and the upper fragment pressed strongly froni, 1
within against the skin. In spite of all our eftbrts to prevent it, tho 1
skin, although not compressed by any part of the apparatus, was at f
last perforated. Fortunately, this took place twenty days after the
accident; consolidation had already begun, and this late wound had' J
no unfortunate consequence. The seat of the fracture, undoubtedly j
protected by the callus, did not suppurate, but the skin aad the super- J
ficia! part of the denuded bone did suppurate, and left a ciuatrica j
slightly adherent to the bone. 1

II. Compound fmclure wtlh a large wound.— -Ws have in No. 5 a |
man 40 years old, who oflers an example of compound fracture, Thia I
lesion also is below the middle of the leg, and nearly at the place of
election. It was caused by a fall from a height of two or three yards,
in consequence of the breaking of the ladder on which the patient
was standing. I do not think a direct cause intervened in the produc-
tion of the fracture. The upper fragment of the tibia, which has not
the form of a V, projected at the time of the accident through a slightly
oblique wound which was an inch and a half long, the reduction was
easily made; the fracture does not seem to be comminutive, but there is
a wound of considerable size which evidently communicates with the
seat of this fracture.

The prognosis is much graver, and the treatment will be more difi
cult than in the preceding case.

I shall try occlusion again; but although the edges are not much j
contused, I do not hope for immediate onion of the whole wound, and "■
suppuration of the bone seems inevitable. I shall leave the collodion
dressing in place until I am warned by spontaneous pains and those
excited- by pressure that pus is collecting under it and should be let
out. As soon as the presence of pus becomes incontestable I shall
continue to keep the limb us immovable as possible in the trough,
which will be lined with oiled silk so as to avoid a contamination \
which would compel us to raise the limb too often in order to r
tain the indispensable cleanliness; the dressings will be renewed |
morning and evening. How will these dressing be made? We hava, |
to choose between several methods. Those which are most used to- ]
day are alcohol and carbolic acid (I per mille .solution). To use it
we begin by carefully removing with sponges all the pua which has
collected upon the sides of and behind the limb ; sponges are not used
for the wound ttsell', we content uurselvea with carefully wiping it

108 FRACTDBKS OF THE LIMBS,

with lint soaked in one of these liquids, and we exert pressure about
it so 33 to favour the escape of the pus which might coHeet in some
neighbouring pouch. If we find any of these pouches, which are not
too (ar from the sliin, we open them, and, if possible, pass drainage-
tubes. In these oBsifluent suppurations which threaten pyiemia it is
important that the pus should not remain, for then it stagnates, decom-
poses, and may furnish for absorption the putrid materials which en-
gender purulent infection.

When the wound has been cleaned, balls of charpie soaked in com-
mon alcohol unmi.ted with water, or in the carboiio acid solution, are
introduced into it, and into its cavities if they are accessible. Over
them are placed one or more compresses soaked in the same liijuiil, the
whole is covered with oiled silk, and then the apparatus destined to
keep the limb immovable is completed.

Are there any reasons for giving the preference to one or the other
of these agents? I prefer alcohol during the first fifteen or twenty
days, because its effect is to diminish suppuration, and the less abun-
dant the suppuration the less does the patient weaken, and the fewer
the materials susceptible of putrid decomposition. It is also possible,
but it has not yet been demonstrated, that alcohol, by coagulating
csertain albuminuous principles of the pus, modifies them in such
a way that their putrid alteration is rendered more difficult Perhaps
also the alcohol, by its astringent action, obliterates some of the lym-
phatics and bloodvessels which might furnish passage to the putrid
poisons. All these opinions have been uttered with a certain enthu-
siasm by the partisans of alcoholic dressings; but only one of tliera
has been proved by clinical observation, that one is the diminution of
suppuration. For this reason alone alcohol should be used during the
first days. You will rarely see me continue its use after the twenty-
fifth or thirtieth day, for if it diminishes suppuration, it also retards
cicatrization. By long contact with it the granulations become small,
the wound grows pale, and becomes painful sometimes, and does not
dry over, if not in all cases, at least in a certain number.

I shall then begin with the alcoholic dressing; then if, at the time
when purulent infection is less to be feared, I find that cicatrization
advances too slowly, I shall subatitute carbolic acid, which, without
increasing the suppuration, generally maintains on the surface of the
wound that rosy colour which indicates the regular work of repair.
Of course, during the dressings, I shall examine from time to time
with a probe to see if there is not some loose splinter to be removed.
All the abscesses which form wil! be opened freely, and a general
treatment with tonics prescribed. After the twelfth or fifteenth day I
shall give the patient a drachm of phosphate of lime morning and
night in his soup ; he will also have five drachms of brandy daily, and
all the nourishing food which he can and will accept, and which we
have at our disposal in the hospital ; finally, we shall try to obtain the
best possible aeration of the ward. In this respect we are not as well
provided for as I could wish. This patient is one oi' those for whom
an isolated, well-ventilated, well-warmed room is necessary, or for
whom, daring the hot season, permanent or intermittent ijuttrters ia a

FBACTUBB3 OF THE LOWER THIRD OF THE LEG. 109

tent or cabia like those which have just been built at St. Louis, Cochin,
and Lariboisl^re, would be of the greatest use, Eemember this, thai
of all the means preservative against purulent infection, immersion of;
the patient in a very pure atmosphere is by far the most important.

I have nol raised, gentlemen, an important question which is (3is--
cussed by all our authors in the chapter of compound fractures, that
of amputation. Why have I not mentioned amputation to this
patient? Because, in my opinion, he may get well and preserve the
leg, and indeed his chances of dying are a little less than if I should
now make an amputation, which would belong to the category
mitive amputations, that is, those which are made before the appearance:'
of traumatic fever.

Notice first that the dangers from which I should wish to protect
bim are exactly those to which he would be exposed after an amputa-
tion at the place of election. His wound exposes him to a traumatic
fever, which may be severe and even fatal, that is true, but amputation
exposes him to the same. His wound exposes him especially to purulent-
infection, but that also is what we fear the most aft^r an araputatioa.
His wound exposes him in a certain degree to traumatic eryaipelaa and'
to a consecutive hemorrhage. But would amputation preserve him
from them ? Would it not rather expose him even more to secondary
hemorrhage? His wound may perhaps leave him with an infirmity
jid a limp, but would not the necessity of wearing an artificial leg

]

■

^^^d a limp, but would not the necessity of wearing an artificial leg ^^j

^HQeo be an infirmity ? ^^^|

^^B- Amputation would be justified only if I was certain that he wagi^^^f

^^piore likely to die by the injury than by the mutilation, through ou»^^|

of these complications. Now, upon this point I am in the most com- ,'.

plete ignorance. I see in the regularity, which is still considerable,

of the wound, in the presence of a fracture but slightly comminuted,

■ the very moderate disorder of the soft parts, conditions which make ^_
e hope for a cure; I recognize that my hopes do not go very far, I ^^|
ill even admit that the chances of death are greater than those of ^^|
covery. ^|

I should like to show you by figures the proportion which exiatg
between these two chances, but I have not recorded all the facta which
have passed under my observation with sufficient exactitude to offer
you the figures. I know that in my hospital practice I have seen
more patients with compound fracture of the leg with large wound
die than recover. In my private practice, on the contrary, of six
patients of this kind four got well and two died, one of them of
tetanus, and I am convinced that when the conditions of aeration in
the hospital becotne the same as in private practice, we shall have
the same results. Furthermore, I do not think I am mistaken in
assuring yon that, even with these good hygienic conditions, the mor-
tality after primitive traumatic amputation is a little greater than afler
attempts to preserve the limb.

Notice that this mutilation adds one cause of purulent infection to
those which exist in consequence of the wound itself, I refer to the
serious moral perturbation. The man who, in full health and unex-
pectedly, is obliged to sufl'er the loss of a limb, without having been

I 110 FRACTURES OF THE LIMBS.

^H led to it progressively by long sufferings and a. wretched existence in
^f a hospital bed, as ia the case with tliose whom we amputate for sup-
purating white BweltingB, without having been led to consider this
mutilation a relief, ia very much affected thereby. Now you may be
sure that this great moral shock ia a powerful cause of the accidents
which follow arnputatioQ. Our patient, seeing that we have a strong
hope and desire to preaerve hia limb which he knows ia dangeroualy
injured, is in this respect in better conditiona, and for that reason I
think he is lesa likely to die than if I ahould amputate.

I recognize none the lesa that in the present state of surgery this
problem will not receive a rigorous solution until we learn from the
statiatica of a great number of observations in what proportion

Ipatieuta afleeted with such wounds as we have before us recover, and
in what proportion they die, so as to compare these proportions with
those given by primitive traumatic amputations. These statistics are
very difficult to establish, because no single surgeon has enough per-
sonal facts to be demonstrative, and because in statistics comprising
facta furnished by different surgeons, we can never be sure that the
observations are identical, that, for example, they do not include frac-
tures with much and with little shattering and those with small
as well as large wounds. Moreover, success depends very much
upou the care which is given to the patient and upon hygienic coq-
^^ ditions. Now if they place in the same statistics patients who have
^L not been properly dressed, or who have breathed a vitiated air, and
^H those who have been subjected to the opposite conditions, the general
^F result is not what it ought to be. In the lack of these rigorous
proofa I act according to the reaaona which I gave, and I advise you,
whenever you meet with a compound fracture with a moderately large
wound like the one I now speak of, but without much crushing of the
soft parts and the bones, to do conservative surgery. I advise this
particularly if you practise in the country, in small towns, in small
hospitals, that is to say, in an atmoaphere which is not vitiated by
crowding.
^M I do not mean to proscribe absolutely primitive amputation in all
^B oases of compound fracture of the log.

^H If, contrary to my expectation, I saw gangrene appear in a few days,

^™ especially gangrene with emphysema, I should not hesitate to propose

amputation. 1 do not think it will happen in this case, for the fracture

is by indirect cause, and in such eases gangrene is much less common

than when the fracture is by direct cause.

»So, too, when the injury is accompanied by a considerable crushing
of the marrow, by extension of the fracture to the tibio-tareal articu-
lation, and imminence of suppuration in this joint, it ia hardly to be
doubted that the patient will be carried off by intense traumatic fever
or by purulent infection, and that the chances of recovery are a little
greater after amputation. This then should be proposed to the pa-
tient. Gunshot wounds cauaed by large projectiles and with con-
siderable shattering, direct fractures by a heavy body, such as the wheel
of a wagon, and certain V fractures, sometimes cause lesions which
authuriae as to expect no good from conservative surgery.

[FRAOTUKKS OF THE LOWER THIRD OF THE LEG. Ill \
Some of yoa saw me last year perform amputation the day after the ]
jident upon a patient the lower part of whose leg had been caught i
under the wheel of a heavily laden cart and presented a comminuted
fracture with laceration of the muscles and tendons and opening of the •
tibio-tarsal articulation.

I made another one at the same time in the environs of Montargis 1
for a similar fracture with enormous shattering caused by the point-
blank discbarge of a fowling piece.
Both patients succumbed.
^L Let na suppose now that our patient in No. 5 has had only a mr
^htte traumatic fever, that suppuration has set in regularly, and that i
Bjfrom twenty to thirty days have passed without purulent infection, ,
floes that mean that he would he safe and that, consecutive amputation j
might not become necessary ?

You know, gentlemen, that supparating osteitis takes in these casea 1
the form of necrosis. Now, if this necrosis should invade a great |
part of the bone, if, in consequence, exfoliation should be very slow, |
if suppuration, having become very abundant, should undermine tha '
patient's strength, if it was accompanied by continuous fever, with
exacerbation at night, loss of appetite and of fiesh, sweats, diarrhoaa,
if finally the patient seemed in danger of dying of hecticity, amputa-
tion would be indicated. It would be indicated all the more because,
if, by chance and against all expectation, the organism should resist this
drain, the patient would recover with fistul£B| a more or less painful
hyperostosis, fresh necroses, more or less frequent attacks of inflamma-
tion, rebellious ulcers, in short, the whole series of permanent and re-
curring complications which we see about large necrosed bones. He. J
would not be able to walk, and would lead a miserable existence, froniB
which amputation would certainly save him. M

Notice, too, that we should no longer have to fear, as at the begin- '
ning, the moral effects of which I have spoken. The patient would
see that the limb would not get well, the surgeon would show hiiu
little by little the impossibility of preserving a useless limb, and would
lead him to accept imputation as a benefit. But it is probable that it J
would be necessary to amputate the thigh instead of the leg ; for tha I
supurative osteitis would undoubtedly have invaded the whole of the 1
tibia, and it would be better to apply the saw to the healthy femuF M
than to the diseased tibia. I

No one would think to-day of discussing the question of amputa- I
tion conformably to the prize subject proposed by the Acadiimie dg fl
Chirurgie in 1755, under the title : '^Ampulalion hemg absolutely necat^m
BfU'y in wounds complicated with cniskmg (fracas) of the bones, determin&M
the cases in which the operation should be performed immediately, andikoatm
in which it is prober to defer it." Faure, who obtained iha prize,^ did I
not answer the question as it was asked, and applied himself only ta I
proving, in a general way, that secondary amputations were mora I
^^uccessful than primitive ones. i

^K Modern statistics have not confirmed Faure's opinion; but it is not!

^^L ' Fasre, Frix de I'Acad^mie da Cbiraigie, tome iii. in 4to. p. JSSi J

112 ' FBACTUKBd OF THE LIMB3.

tlia lea3 true tliat, in practice, the problem cannot and ought not to be
Btated !i3 the Acadt^mie de Chirurgie stated it.

I rejected primitive amputation because it was not indicatei^, and
because I could hope that it would not become necessary; I rejected
it, and did not postpone it. If later I propose amputation, it will bo
because complications which I knew to be possible, but the appear-
ance of which could not certainly be foretold, have arisen and have
caused an indication which might possibly have remained absent.

In a word, in these great traumatic lesions we propose amputation
when it becomes necessary; but we are never free to say in advance
that we shall perform it at any one period of the disease rather than
at another.

(The patient who was made the subject of this lesson suppurated
for more than six months, lost three large fragments, and recovered
finally with a solid callus, consecutive to the bony transformation of
the granulations, and with a hyperostosed tibia. He left ua, walking
with crutches, he came to see us twice during the following three
months, still unable to do without crutches; since then we have not
seen him.)

LECTURE XIY.

FRACTURES OF THE LEG.

I. COmpouitd fractara or tbe lower third of the leg wltli small wound and em-
physema. Distinction betweun primitive or aerial empbysenia, and oonseouUvs
or gangrenous emphysema. 11. Fracture with large vertical wonud and nom-
meuoing gangrene. Imioineuce at dangerous fieptioreuila — Amputation.

Gentlemen: I, Fracture with small wound and emphysema. — We
saw this morning a man who was admitted yesterday with a com-
pound fracture, the wound being a small one, below the middle of the
leg very near the place of election, of which I have so often spoken.
It ia one of those cases in which we have a right to expect recovery
without suppuration, by means of occlusion with collodion. I call
your attention to-day to apeculiarity which is notoften seen. Placing
your fingers over the fracture and pressing lightly you feel the fine
crepitation which characterizes emphysema. Light percussion by
snapping with one finger, gives sonority, We have then here an
infiltratinn of gas about the wound. This complication, or rather
this coincidence, was pointed out for the Srst time by Velpeau in
1839,' was well studied by one of his students, Dr. Boureau, in 1852,*
by Morel -La vail i5e,* and lastly by M. Demarquay.*

■ Velpeau, Traitf de MMeoine opSratoire, 2d edition, tome il. p. 321.

' Boureaa, Tlitoe de Paris, ISSti.

a Morel-Lavall6e, Gazette MSciioale, 1883, p. B20.

* Demai-q nay. Tra ltB de Poeamstologls mSdicftla, p. 28!

* Opinions varied upon the first question because it is difficult to "
give a rigorous demonstration of the way in which this empbyaema
is produced. I admit, with M. Demarquay, that it might tiriae in two
waya, either by the infiltration of the external air into tbe aubcuta-
imeous cellular tissue, or by the spontaneous production of gaa con-
Bscutive to a perversion of nutrition causing either a decomposition
^ the tissues, or an exhalation similar to that which takes place ia
"tlie stomach and intestines of nervous people, I think that here we «
have to deal with tbe first variety, infiltration of external air, aiida
that this air was introduced through the wound by muscular conj
tractions which during and since ibe accident have caused a sort tXm
fepiration about the little wound, according to the mechanism so wcUl
■Bacribed by Morel-Levalli5e, It is then a primitive and not a coa»B
llBoutive emphysema, as it would be if it resulted from the aponta'^
ileous formation of gas in the tissues.

I base this opinion upon two reasons: 1st. The emphysema ap-
peared early, for twenty-four hours have not yet passed since the acci-
aent. Emphysema by decomposition and exhalation rarely appears
^fore forty-eight hoars. 2d. Its appearance was accompanied by J
Bo serious general symptom; neither chill, nor quickening of thtfB
Bnlse, nor augmentation of the temperature, nor delirium, etc. Enjti.fl
physema by decomposition, preceding traumatic gangrene, is aocomiH
panied by grave general symptoms which announce a speedy death. I

For the second question, that of the clinical signification, I hesitataiB
no more than for the first. This emphysema indicates nothing seri- ■
ous. Velpeau and Boureau, in saying that it indicated approaching
death from which the patient could be saved only by prompt amputa-
tion, committed an error which it is easy to understand. Writing at
a time when no one had yet spoken of this phenomenon, they re- J
mained under the impression of the facts which they bad witnessed, I
in which the injury ended promptly in death. They were led into I
error by one of these circumstances : either the death was caused by '
the wound itself, without the emphysema having added anything to
tbe gravity of the situation ; or instead of a primitive emphysema by
the entrance of the outer air, they had perhaps to deal with a con-
aeoutive or gangrenous emphysema, which they were not able to dia- J
tinguish from the first, I

To-day we are perfectly informed upon this point by the observa- ^
of the clinieists, and by tbe experiments of M. Demarquay
animals. Infiltration of air giving rise to this primitive em-

lyaema without fever ia in itself not dangerous, adds in no way to
le gravity of the wound, and by no means indicates amputation.

Watch this patient carefully, and I can assure you that if, as I
hope, the small wound cicatrizes without suppurating, the infiltrated ]
air will be slowly absorbed, the emphysema will disappear in four or |
five days, and the fracture will behave like a simple one. i

(These predictions were verified, and the patient left the hospital
ibree months after bis admission.)

FBACTUBE3 OF THE LIMBS,

II. Fracture of the leg with long vertical mound and commencing gnv-
grene: ampulation. — We have had, gentlemen, for two days in No,
45, a teamster 46 years old, quite vigorous, but addicted for the last
ten years to the use of alcohol, over whose right leg one of the
wheels of his heavily-laden' wagon pasaed. We found yesterday
morning, the first day of the accident: —

1st. A fracture of both bones, of the toothed variety, a little above
the junction of the middle and lower thirds, with very few splinters.

2d. A wound upon the anterior part of the limb five inches long,
and parallel to the axis of the limb ; or, if you prefer, to the adjoin-
ing crest of the tibia.

"1. A quite extensive loosening of the skin on the outer and inner
i of the wound.

4th. A denudation of the two fragments of the tibia, that is, a dis-
appearance of the periosteum from the outer and inner faces of these
fragments for a distance of at least an inch from the fracture.

This compound fracture is one of the moat dangerous that you can
meet. It does not owe this gravity to the multiplicity of the frag-
mems, and to the crushing of the bone and the medullary substance.
If this crushing existed with the other conditions of which we are
witnesses, we should be in presence of the variety which is unques-
tionably the most dangerous of all fractures of the leg. That which
gives the prognosis in this case an unfortunate character is first the
alcoholic habit, a habit which, without our being able to explain it,
renders the subjects much less likely to recover from great traomalie
lesions ; and second, the action of the body which produced the in-
jury. This evidently is a fracture by direct cause; now in all these
fractures the effects of the contusion of the soft parts are necessarily
added to those of the solution of continuity of the bone, and as the
wagon was very heavy, we may fear that the contusion has been se-
vere enough to ultimately produce gangrene, if not of the whole
limb, at least of a notable part of the skin. Now, at the time of the
first examination it was precisely gangrene of the loosened skin
which I declared possible and even probable. Upon what did I baise
this fear ? First, upon the oommenioratives which indicated the pas-
sage over the leg of a very heavy body.

Notice well, gentlemen, that the wound is a vertical one. Now how-
can the wheel of a wagon, passing transversely or obliquely across
the leg, produce a vertical wound? It does so by forcibly pressing
the skin against the crest of the tibia which becomes, in consequence
of this pressure, the real vulnerant body, and cuts, from within out-
wards, the skin forcibly stretched over it. Certainly, it is not because
the crest of the tibia has been the vulnerant body for the skin that
the wound is dangerous ; but this mechanism of the wound necessa-
rily supposes very violent pressure, and consequently the most serious
results of the contusion.

Notice, also, that the skin is loosened for a certain distance about
the wound. You know what this loosening is, for I have often spoken
about it; it is the result of great oblique pressure, that is to say, it is
produced by very heavy vulnerant bodies which, instead of coacen-

_ lio

FBACTITRES OF THS LEG, 115 1

trating tlieir action upon a point parallel to the axis of the leg, pass
transversely or obliquely across this axis. The wheel of a wagon, a
rolling cask, act in this way. Now, in passing obliquely, the vulne-
rant body slides the akin over the subjacent layers and causes more '
or less extensive rupture of the subcutaneous connective tissue. It 19 J
precisely this ruptare which explains the loosening seen in our patient. '
You understand that by this loosening a large number of the blood-
vessels which go from the subcutaneous layers to the skin are torn,
and consequently this membrane loses a part of its means of nutri-
tion. You know, also, that the pressure crushes and destroys part of
capillaries and nerve-filaments, another cause of the death of the
1. Consequently a patient over whose leg the wheel of a wagon
IAS passed, causing a vertical wound, a loosening, and a violent con-
tusion of the skin, is much exposed to gangrene of tbe latter. He
may also, if the pressure has extended far enough to cause rupture of
the deep vessels and nerves, have gangrene of the whole limb. You
saw me yesterday seek the pulsations of the dorsalis pedis and poste-
rior tibial arteries. Having found them easily, I concluded that the
tibial arteries had remained intact, and that doubtless the patient was
iiot exposed to general gangrene of the limb, gangrene which I should
have considered imminent if I had not found these pulsations upon
the wounded side and had found them on the other. But I still feared
mortification of the skin, and for that reason I spoke to the unfortu-
nate man of amputation of his leg. He refused and asked for twenty-
four hours For reflection.

This morning you saw that the skin about the vertical wound was
cold and insensible to the prick of a pin, and that it presented a yellow-
brown or livid colour, which it did not have yesterday. We also
found on each side and behind an emphysematous crepitation which
I attribute to commencing putrid decomposition of the connective
tissue. The patient has as yet no traumatic fever. Bat this fever
will undoubtedly soon appear, and that is why I urged the patient to
submit to amputation

Why did I urge this? First, amputation is indicated because, as
the patient is destined to lose a part of the skin of the leg, the repair
of the integument, supposing death not to occur, would be very slow,
and all tbe more difficult because the bones would be very much en-
larged by condensing osteitis; and if the uicatrtx finally formed, it
would be very thin and probably adherent to the bone, ao that it
would constantly tear and be covered with relapsing and rebellious
ulcers which would constitute a deplorable infirmity.

Further, amputation is indicated now, and it is urgent. For to the
:r dangers which threaten the patient, we must add those of which
gangrene may be the occasion. For sometimes, although only
the skin and subcutaneous cellular tissue hiive been destroyed, wa
see, after the third or fourth day, grave general symptoms arise, burn-
ing fever, delirium, jaundice, and prostration, followed by a rapid
tlsatb.

I admit that these accidents may be attributed to traumatic fever,

ich is thought to-day to be a variety of septicemia. Bat they

FBACTUaaS OF TUB LIMBS.

would be much more intense than usual, and it is allowable to think
that this greater intensitj would be due to the worse character of the
septicEBniia, for the putrid gases which form under the skin, and there
produce the consecutive emphysema, might be reabsorbed and become
the cause of a more serious poisoning than that of the ordinary trau-
matic fever. However that may be, in such a case, when gangrene
has commenced with emphysema, death is imminent unless the putre-
fying part is removed in time. That is why I urged the patient more
strongly than I did yesterday to submit to amputation.

Fortunately the gangrene and emphysema have not e.ttended to the
upper part of the leg, and we can amputate at what is called the place
of election, and still be beyond the limits of the trouble,

{Amputation was performed. The patient did not succumb to the
traumatic fever, but he was carried off by purulent infection f "
days lifter the operation.)

LECTURE XY.

ction Sfiu^H

BI-MAILEOLAR AND SUPRA- MALLEOLAR FRACTURES OF THE LECf.

Bi-malleolar fraotara — Obsonrlt]' of the meohsiiiBm — Tiro oases, one williont djs-
plaaemsDt, the other with tlie dUptnoeiaeut dHserlbad b^ Dnpujtrtm — Difforaul
indiaatioua for the tno pat ieuta— Simple retoatioD for tkH Srst — Rutentfoil irith
addnotioii of the foot for tbe avaoiid. II. Siipra-mallHOlar frautnro — Dlspl.
ment diffioult to correct — Possible esubar in casus of thia bind — Kspli
by more crushing beblad tbao in frool — Friunipal iudicitiou la to uroii

Gentlemen: I. £i- malleolar fracture, — We have at thia momeni
in the wards two patients affected with simultaneous fracture of the
lower extremity of the fibula and the internal malleolus.

I give this variety of fracture the name of bi-'inalleolar, although
I recognize that sometimes in the fibula the solution of continuity
occurs a little above the part which, strictly speaking, constitutes tbe
external malleolus.

In both cases the fracture was caused by a misstep in which the
foot was subjected to a certain degree of torsion. I wish I could tell
you if the foot, at the moment of the accident, turned about its ver-
tical axis from within outwards, so that the outer facet of the astra-
galus pushed the external malleolus backwards and outwards, while
strong traction was exerted upon the internal malleolus by means of
the lateral ligament, and that we might, following M. Maisonneuve,

ineave, Fractured dn I

i (Arcbivaa GC'ii. du M^dttcm

IMALI.EOLAK FRACTDRKS OF THE LKS. IITI^H

explain the fracture of the Bbula by divnlsion, and that of the inteiv^^J
nal malleolus by traction. Nor can I tell you if at the time of thet^H
accident the foot turned about its antero- posterior rather than ita ver- ^H
tioal axis, nor if it tooif, to use Malgai^ne'a expresslona,' the positioul^^
of adduction, or that of abduction. For the patient could give m«i ^^
no precise information as to the way in which hia foot turned. ^H

no precise information as to the way in which hia foot turned.

Reading the works of the two autliors just mentioned, and Dupuy-
trenV much earlier one on this subject, one would believe from the
manner in which they speak of the mechanism of fractures of this
kind, that they were able constantly and very easily to confirm by
their patients the theories which they developed upon it. But it is J
not 30. The patients can almost never say how the foot turned, and.
can give the surgeon no information upon this point which can clet
up his diagnosis and prognosis.

I admit willingly that we can study upon the cadaver certain points ]
of the mechanism of fractures of the fibula, and especially that which'
relates to the effects of torsion of the foot. Bvit we can never know
if, in an accident, everything has taken place as in our experiments,
for two reasons: (irst, because the patients, as I told you, do not
know what has taken place; and, second, because in the living body
we have, added to the torsion of the foot, energetic muscular contra&*»J
tions, and the weight of the body upon the lower part of the leg and |
the foot while they are in a vicious direction. These difficulties ren-
der the results of experiments upon the cadaver inapplicable to the
clinic, and cast, it must be frankly admitted, great obscurity upon the
mechanism of fractures. Bat on this point, as on many others, I like
better to tell you that we do not know, than to give you false and
incomplete explanations.

In one of our two patients the double fracture is accompanied by
no deviation of the foot, and no other deformity than that which re-
sults from the swelling. The diagnosis, nevertheless, is incontestable..
Not only have we found that sharp pain on pressure above the exter-'l
oal malleolus and at the base of the internal one, which is one of the- '
probable signs, but we were able to feel crepitation by the three prin-
cipal raanceuvres recommended for that purpose: —

IsL For the external malleolus, pressing with one finger upon the
point of this malleolus while the other hand holds the lower part of
lie leg firmly; for the internal malleolus,seizing it betweentwo fingers,
and moving it backwards and forwards,

2d, Raising the leg, holding it firmly with one hand, seizing the
foot with the other, the palm of which embraces the sole, while the
thumb and middle finger are placed by the ankles, and moving it
alternately outwards and inwards, sometimes without rotation, that
is, carrying it bodily sideways, sometimes with rotation about i
antero- posterior axis.

3d. i'ixing the leg upon the bed, without raising it, with one baud,- I
the fingers of which are placed over the ankle, and moving the point- 1

f
I,
t

I 118 FRACTL-RK^i OF THK LIMB

BllE

^B of the foot outwards with the other, thua giving it a movement of
^M rotation about the verticd axis of the astragalus.
^M In the other patieot, on the contrary, you saw most notable de-
^H forrnity. When the two hmba are compared without raising them
^B we see that the right foot (the iiijur^ side) is distinctly carried out
^r wards, that its external border is slightly raised, and its internal bor-
der lowered, in consequence of the rotation about the antero-poalerior
axis which coincided with the abduction. Two finger-bread tha at>ove
the external malleolus is a depression which Dupuytren compared to
an axe-cut. The internal niaUeolus projects below the akia;, which is
very tense and seems threatened with rupture. But this projection
is a little above the point of the malleolus, and is formed by the irreg-
ular surface of the upper fragment of a fracture which passes near
Pthe central part of this eminence.
You saw that I reduced the deformity by fixing the leg with one
hand, and carrying the foot inwards with a double movement of
bodily transportation and rotation about its an tero- posterior axis. I
showed you that during this manceuvre the point of the internal mal-
leolus, forming the lower fragment, returned to its place, and that
after the reduction, the skin was much leas tense and no lunger threat^
ened with gangrene or perforation. ^|

The prognosis in these two patients is very rlifterent. ^M

In the former we have to fear neither trouble on the part of thl|
skin, nor consecutive suppuration. We are sure that the patient will
I recover without deformity. The only ultimate troubles will be those
of tibio-tarsal arthritis and synovitis of the neighbouring tendons.
These troubles, of which I often speak (see p. 70), are inherent to all
fractures near articulations, and of course to these which communicate
with the joints, as these two must inevitably do. These arthrites
and synovites differ in being accompanied by lesions, sometimes tem-
porary, sometimes of very long duration, or even incurable, which
limit the movements, render them painful, and make it difficult to
walk. These lesions are a thickening of the synovial membranes,
and consequently a rigidity; or, if you prefer, a loss or a notable
diminution'of their extensibility, artificial union by means of false
membranes, between the articular surfaces and tha parietal synovial
between the tendons and their sheaths. In oi-der that the articular
movements and the gliding of the tendons may resume their physio-
logical conditions, it is necessary that these lesions should disappear.
That never occurs in less than from four tu six months, and often
ranch later. The length of time that is necessary depends especially
upon the age. Especially during youth, and until about the age of
forty years, the synovial membranes lose quite promptly these con-
secutive inflammatory lesions After forty, and especially after fifty
, years of age they disappear much less rapidly, particularly if the
Bubjects are rheumatic or gouty. It is then that you see the patients,
especially the women, walk for years slowly and painfully with the
help of a cane. In this respect the condition of our first patient is
favourable, lie is thirty years old, and is not rheumatic; we may
then hope that be will feel the consequences of his articular fracture

V MALLEOLAR FRACTURES OF TUB LER. 119 ^|

H^r only five or six monttiR, I do not mean that he will be confined
Utct hia bed during all this time; on the contrary, fracturea of this
* kind, like those oF all the small bones, like those of all the extremities
of long bones, consolidate rapidly, and it ia not necessary to beep the
limb immovable for more than thirty days. After that immobility is
no longer of any use to the fracture, and it may have disadvantages
for the articulation already inflamed by proximity, and especially for
the small articulations of the foot. In this respect, I make a distinc-
tion, as I have already shown you, and as I shall again show you
hereafter, between the joint or joints which are near the fracture, and
those which are more or leas removed from it. The first present the
- lesions and symptoms of arthritis ; but as these lesions are the result
either of the propagation of the inflammatory process from the frac-
ture to the synovial membrane, or of the traumatism in which the
articulation has participated, we cannot tell to what extent the immo-
bility has contributed, and in this respect M. Teissier (de Lyon)' in-
voked a number of facts which are not demonstrative, when he cited
examples of arthritis of the knee with neighbouring fracture of the
femur. The second, on the contrary, those which are more or less
distant from the seat of the fracture, and which we may suppose not ^^
to have participated in the efTects of the traumatism, may alter it^^l
consequence of prolonged immobility, and they alter the more as the^^f
articulations are smaller and tighter, such as those of the hand and ^H
foot. There would then be reason to fear that by keeping the foot
immovable too long, we might produce in the small articulations of
the tarsus and metatarsus the lesion pointed out by Teissier and

t Bonnet de Lyon,' which are followed by more or less painful pro- ^_
longed rigidity. ^H

» To return to our HthI patient. I say then that he will have an ioer.-^^f
(table tibio-tarsal arthritis ; but that as he is young and not rheumatic ^|
this arthritis will remain subacute, and will not pass to the state of
curable but prolonged chronic arthritis, nor to that of incurable dry
arthritis, and as I shall not leave him very long in the immovable
Apparatus, he will also escape those arthrites caused by immobility
tamd the consecutive stiffness which we see especially in the small
prticulations.

As for our second patient, if we should do nothing or if we should
lot treat him properly, the prognosis would become very serious.
Jtrst, if we should not make the reduction an eschar might easily form
vep the upper fragment of the internal malleolus and cause its sup-
uration and that of the articulation itself. If suppuration did not
!cur consolidation would take place with the foot ia its present posi-
jn. That would be a deformity, and at the same time an infirmity,
r the patient would walk upon the inner border of the foot and not
wn the sole. The internal lateral ligament and the inner portioa
F the synovial membrane would be constantly strained, causing re-

1 Telisier, MfimairH sni- le

41).

■ Bonnet, Trails des Mabi

fl20 FRACTCRES OF THE LIMBS. •

H-12'

^H peatetl sprains and incessant tibio-tarsal artbritis, which would corn-
el pel the patient to walk very little and to rest himself frequentlj.
^H Treatment. — That of the first patient will be very simple. In a few
^V days we shall wrap his foot ana the lower part of the leg in a silicated
^H apparatus which will be removed about the 25th or 30th day, count-
^f ing from the accident. After having taken it off we shall permit the
^ patient to walk with crutches ; we shall advise him to move his foot
while lying in bed, and wa shall ourselves communicate some move-
ments to it every morning, in order to restore suppleness to the artica-
^H lationa and tendons. We shall apply prolonged frictions, either with
^K the naked hand and grease, or with a flannel, and finally we shall
^^k give him some sulphur baths.

^H For the second one we have to make and maintain reduction. You
^H saw that reduction was quite easy, but that the foot, abandoned to
^H itself, returned promptly to its vicious position. It is then necessary
^M to apply an apparatus which will hold the foot firmly in place. Du-
^H puytren understood this indication perfectly, and met it with an ap-
H paratos which was as perfect as was possible at a time when they did
H not use immovable bandages. This apparatus, which I have applied
H temporarily upon this patient because there was too much swelling to
H allow of the immediate application of an immovable one, and which I
H am glad to show you, because you may be obliged to use it yourselves
^r sometimes, is composed: —

1st. Of a very long bag filled with chaff and folded at the middle,
which is placed, thus folded, upon the inner side of the leg, taking
care that it does not descend as low as the internal malleolus and that

fit leaves it free; for you understand that from the moment we fear
an eschar at this point we must abstain from compression.
2d. Of a wooden splint long enough to cover the bag and extend
beyond the sole of the foot, so as to leave a gap between itaelf and the
foot.
8d. Of two bands, one of which is rolled about the upper and mid-
dle portion of the leg and fastens the bag and splint there, and the
other, as soon as the foot has been brought inward by the manceuvre
of reduction which I indicated a little while ago, forms a figure of tJ
about the lower part of the leg and the foot, holding the latter close
to the splint.

This dressing meets the indication very well if it is sufficiently
tight over the foot and is renewed almost every day, for it gets loose
very easily. You saw that after the apparatus had been applied I
placed the limb upon a large and rather high cushion of chaff, resting
the limb upon its outer side, as Dupuytren advised in cas&s of this
kind, and as, before him, Pott advised for all fractures of the leg.
This position has no advantage when the limb is in the Scultet band-
age, but it is much more convenient whenit isset withan inner splint.
A hoop to keep oft' the weight of the bedclothes completes the dreaa-
ing. Of course if the bands are too tight and the patient suffers, or
if the inner border of the foot is pressed so tightly against the splint
as to give pain, it would be necessary to loosen the bandage or to
renew it before the end of the twenty-four hours, Thsre is, however,

MALLEOLAR FSACTUBKS OF THE LEG. 121

no reason to fear gangrene by constriction, for the fractured region \if,
not entirely oompriiied in the apparatus, since on tbe inner side ihQ
band passes over the splint and not over the foot itself.

If after forty-eight or seventy-two hours, I find that the inflamma-
tory ewelling does not increase, 1 shall apply an immovable apparatua.
I should wait longer if there were any small wounds, phlyctense, or
scratches which I wished to see cured before thus inclosing the limb.
This delay would be no disadvantage if the Dupuytren apparatus
were renewed every day, and if it certainly maintained the reduction.

It has happened to me aometimes, and some day you may meet with
cases in which you will be obliged to do the same thing, to apply
immovable bandage on the first or second day. Once it was because
the patient had violent alcoholic delirium, and disarranged his appa^
ratus and reproduced the displacement of the foot by his movemeats.
Od two other ocxsasiona it was because, notwithstanding tbe care with'
which I placed the splint and bag, the displacement of the foot rgr
appeared in a few hours, and the skin over the internal malleoli
was so pressed upon as to render perforation or eschar imminent.

The application of an immovable apparatus having been decided
upon, to which should we give the preference? Unhesitatingly to
the plaster apparatus without the addition of gelatine. Why ? Be-
cause it dries most rapidly, and if the foot is well drawn inwards and
the reduction maintained during its application, I am ^re that when
the operation is terminated the bandage will be dry and will keep the
parts as I placed them.

If by chance, in a case of this kind, you do not have proper plaster
at your disposal, apply a bandage of starch, dextrine, or silicate of
potash; but take care to keep the foot turned in during its applica-
tion, and add to the inner aide of the leg two thick linen cushions,
one below the knee, the other above the internal malleolus, place
over them a long inner splint like that of Dupuytren's apparatus, and
fasten the leg and foot in the same way until all is dry.

The immovable apparatus should not remain more than 30 days in
place. After that time the consecutive treatment is the same as that
described in the preceding case.

II. Supra-maUeoJnr fracture. — The patient in No. 26 is a man 61
years old, a little weakened by age, who, while descending a staircase
in the dark, thought he had reached tbe bottom when he was still
three steps from it. He fell, having, he says, his left foot and leg
caught under his buttocks. You saw that the deformity resembles
that of the preceding patient in this, that the foot is turned outward,
that its outer border is raised, that there is the "axe-cut" depression
above the external malleolus, and abnormal projection of the internal
malleolus with a depression below. The foot is drawn backwards as
well as outwards so that the skin is pressed upon and endangered by a
very large bony prominence formed by the upper fragment of the tibia.
For it is easy to see, by taking the leg in one hand and the foot in the
other, and trying to restore their normal shape, that the principal line
of the fracture is above the line of the malleoli, and passes through
the inferioi extremity of the Libia a few lines above the articulation.

122 FBACTCRES OF THE TIMB3.

mid througli the adjoining part of the fibuln. It is than one of ihosd
fractures which, on account of their position, Malgaigne* Darned
supm-malleolar. You noticed that, after having made an almost com-
plete reduction, I saw the dispiacemeiit immediately reappear, and
that after having placed the limb in a wire trough I saw, notwith-
standing the anterior splint, the foot again turn outwards and back-
wards. I then placed two graduated compresses along the anterior
and inner portion of the tibia, after having first applied a layer of
cotton ; then, adding the bag and anterior splint, and tightening the
straps over them, I managed to maintain, if not the whole, at least a
very great part of the reduction. We are here then in the presence
of a supra malleolar fracture with complex displacement, difficult to
correct.

It is not always so in supra-malleolar fractures; I have seen some,
and Malgaigne also gives examples, in which there was little or no
displacement, and in which reduction was easily maintained. On the
other hand, the present case is not uncommon. Malgaigne quotes two
similar ones from DupuytreD's work in which the splints, the only
apparatus used at that time, did not prevent the displacement from
obstinately reappearing, and the upper fragment of the tibia from
causing a large eschar followed by suppuration and serious accidents.
The patients recovered with a deformity and an infirmity. I myself
had at the Hflpital de la Pitie in 1S86 a man 66 years old, in whom
a similar fracture was followed, in spite of all my care, by an eschar,
suppuration of the articulation and bone, and finally by purulent
infection and death.

To what is the difficulty of retention and consequently this gravity
due? The authors have not explained it, but this is the explanation
which I reached by autopsical examination of my last patient and a
study of one or two specimens in the Mus^e Dupuy tren. The fracture
is undonhtedly produced, or, if you prefer, completed by the mechan-
ism of crushing, that which takes place in most of the fractures of the
extremities of long bones, and which has been well studied, especially
for fractures of the lower end of the radius and upper end of the
femur. At the moment of the accident the upper and lower frag-
ments are pressed against each other by the weight of the body *ind
by contraction of the muscles. This reciprocal pressure has caused
the crushing of the cancellous tissue, a crushing favoured by its greater
fragility which is the consequence of age, and which appears much
sooner in some subjects than in others.

Remember that this patient is sixty-one years old, and that the one
at La Piti^ was sixty-six. The crushing is not regular, it is greatest
at those points where there was most pressure, and those points are
the ones where the muscular action was most energetic. The action
of the peronei, the gastrocnemius, and soleus predominated, and was
undoubtedly favoured by the abduction and extension of the fool at
the moment of the accident. In consequence of this predominat ing
action the sinking and crushing of the cancellous ti.i^sue were gre

' Malgaigne, he. eit.,p. 818.

^■^ MALLEOLAR FBACTURE& OF THE LEG. 123 ^^|

on the outer side and beliind than in the other directions. When we-^^^|

replace the fool in its natural position, it can msiQtain it only if the ^^|

fractured Burfacea are interlocked at some points, but if this condition

is lacking, and an empty space exists there where the crashing baa

been greatest, it is plain that the effect of the tonicity of the muselea

is to draw the foot in the direction indicated by the irregular form of ^^_

tbe fragments. ^^H

If, in other patients, the deformity ia leas, or if retention is easier,. ^^H
it is because the crushing has not been so great, the cancellous tissue ^^H
not having yet acquired great fragility, or because it has taken place ^^H
more evenly, the foot not having turned outwards at the time of the ^^H
accident. ^^|

However that may be, we must not expect in this patient recovery ^^^
without deformity. Whatever we may do, there will remain a deviation
of the fool outwards and a projection forwards of the upper fragment of
the tibia. The interfragmentary callus which will be produced, as in all
fractures of the cancellous tissue, will partly fill tbe gaps, but will not
efface them entirely. It will be the less able to do so because these crush-
ings of tbe spongy tissue are followed by a process of absorption which
removes part of the boue. Great as may be the power of repair, it
is not sufficiently so, especially in a subject advaiicetl in age, to repro-
duce all that has been lost, and so much the less so because the sur-
faces left by the loss of substance are constantly drawn towards one ^^^
another by the tonicity of the muscles, ^^H

That which we desire most of all, and that towards which we shall ^^H
direct al! our efibrts, is to prevent the formation of an eschar which ^^H
would transform our fracture into a suppurating osieo-artbritia. The
indication to be met is that of preventing the upper fragment from
pressing upon the skin, since we cannot meet that of entirely correct-
ing the deformity. How ia this end to be reached 7 By repeated
reductions, and by compression all along the upper fragment, the limb
being kept in a metallic trough. I would not apply the plaster ap-
paratus very early in this case, for I fear the displacement might be
reproduced below it, aud that the dreaded eschar might be caused. I ^^H
prefer the trough, which lets me see what is going on. ^^H

If after a few days I saw tbe skin endangered by the incessant ^^H
reproduction of the liisplacement forward of the upper fragment, I ^^^
might perhaps use Malgaigue's point, Al the end uf hia article upon
supra-malleolar fractures, this surgeon expresses great confidence in
bis process. "As for apparatuses," he says, "the inefficacy of :■

splints and of bands is shown by tbe preceding observatioua, and I ^^M
do ool know any which, under such circumstances, can lake the place ^^H
of my screw apparatus." I should have preferred to this affirmation ^^H
the exhibition of one or two cases in which the screw bad succeeded. ^^^
This kind of fracture presents special anatomical conditions which
might well make it fail. Still, I repeat, if we cannot keep the frag-
ments well enough in place to prevent an eschar we shall make use of
it. Would it not be belter to give the preference to tbe section of
the tendo Achillis, and to hope that, as after this section the foot and'
lower fragment would no longer be drawn upwards aud baekwardsj

theu
the q
suppc

PBACTURB3 OF THE LIMBB.

the upper fragment would no longer project ao much forwards ? I ask
the question, but I do not yet possess any fact upon which I could
upport the use of ibis little operation.

(The patient recovered without eacbar and withont suppuration, by
the aid of the trough and compression distributed all along the upper
fragment. There remained an abduution and a deviation backwards
of the foot, with marked false anchylosis of the tibio-Iarsal articu-
lation.)

LECTURE XYI.

CONSECUTIVE t

sbepe and tt^^^

I. Fraotute of tbs leg eight yenra before— Compiete rsBtoration of sbepe &

tiou— Slight peraisteiit mnsoQlar atrophy — CousideratiooB apoa this atrophy.
II. Another frau'tnre datiug from eighteen moDths — DBformitj due to the per-
Bit'tunce of the prdjaction of the upper fragmeut. III. Old fractnre with hyper-
Dstoais of the tibia. IV. Coiisolidatiou aiuce a year ago— Persisteuce of nen-
ralgio paioB (oBteo-ueuralgia), V. Fracture with persiBteiioe of tibia- tarsal
arthritis. VI. Secorery nith outward rotation of the upper fragment.

Gbntlkmen: Chance has permitted us daring the week to see
here five patienls who had been treated for simple fraelurea of the
leg, either by myself or by other surgeons. This is an opportunity
to call your attention once more to the remote couaequeneea of these
fractures, consequences of wbieh I have often spoken to you without
having any examples to show you.

I. The first is a young man of 25 years, admitted for a wound of
the left arm, who had his right leg broken in the lower third at the
age of seventeen years (eight years ago). You saw thai the confor-
mation of the bones was excellent, that there was no pain along them,
that all the articulations of the foot had their norma! suppleness and
motious, and that hia walk was free, and without limping. Here is,
then, an excellent recovery with restoration of shape and of functions.
It is due to the fact that the fracture was without displacement, or
that, if the displacement existed, it was easy to reduce and keep re-
duced, and it has appeared early because the subject was young, for
at this period of life, when the constitution is not scrofulous, the
tendinous and articular synovial membranes quickly recover the sup-
pleness and extensibility which are destroyed in cases of fracture by
the neighbouring synovites and the lesions caused by the immobility,
I showed you only that the muscles in front and behind were smaller
than those of the opposite side. We recognized it: Ist, with our
eyes, whea the patient was lying down and when he was standiog ;

FIMPLK FBAOTURKS OF THE LEG.

2d, with the hands, by comparing the two calvea. There ia, then, iq,
this patient, a little atrophy of all the muscles of the leg.

Do not wonder at it ; this atrophy is very commoa after fractures
of the leg.

It was twenty years ago that I discovered it for the first time, and
showed it to the students at the Hopital Cochin, I also toM you that
Dr. L^eune,' by my advice, cihoae this atrophy for the subject of his
inaugural thesis. Since then, I have noticed it very often, and have
produced it artificially in auimaia, especially in guinea-pigs whose
thighs or legs I had broken. It would be difficult for me to say what
parts of the muscles this atrophy specially aft'ects. Is it the muscular
fibre itself, oris it the iDterfibrillitry connective tissue? In the studies
which I made upon guinea-pigs, not having had occasion to make
tbem upon men, it seemed to me that both parts were diminished.
Having weighed, immediately after death, the principal muscles of
the thigh, and found a difterence between their weight and that of
the corresponding muscles of the opposite side, I macerated both io'
ether, taking care to renew the liquid often ; at the end of aevea
months the muscles were freed of almost all their fat, those of tho
fractured side had lost as much of their weight as had those of the
other, and there remained the same difterence between the almost
exclusively mui^cular parts which remained. Thence I concluded
that the diminution of weight was made in both the constituent parts
of the muscles, but more especially in their coutractile part. I should,
however, say that it was impossible for nie to thoroughly appreciate
the new anatomical condition of this contractile part; with the naked
eye I saw that it was less red and less vascular than on the uaafieeted
aide, and M. Lejeane remarked the same fact. On microscopical
examination, I found the usual longitudinal and transverse strise.
Upon some of the fibres of the guinea-pig, it seemed to me that the
transverse strife were a little leas apparent or masked by fatly granu-
lations, but it was not so evident tliat I could affirm the chief lesion
of the muscular fibre to be a gra n ulo-fatty transformation. It is
probable, but thus far I haveJiot been able to determine it rigorously
with the aid of the microscope, that this capital lesion is a diminution
of the volume of the fibrilla), and that the general atrophy of the
muscle is the result of the atrophy of each one of its fibrillie, which,
however, have lost neither their normal structure nor their function
of contractility.

Notice, gentlemen, that although the diminution of volume is ap-
preciable by the eye through the skin, the contractile power seems to
be as weli developed as that of the opposite side. Examination with
the dynamometer would perhaps be necessary to form a precise opin-
ion upon this subject. I have never made it, because I did not think
it would lead to any important practical results. What you ought
to know is, that after fractures in general, and those of the leg in
particular, the muscles diminish in size, without diminution of their
mctions, so far as the patients can tell. You should know this iact

'Lejeuno, aee page 71.

I
I

126 FBACTURE3 OF TUK LIMBS.'

warn the patient anil his friends of it, forotherwiaethey would
not fail t<j say that the diminution of the size of the limb was the
result of bad therapeutics.

I shall have said everything that should be said upon this aubjettt,
after having reminded you that muscular atrophy, after fractures, is
inevitable and irremediable. Inevitable, because, whatever you may
do, it will always result; it aeema to me to be the consequence, both
of the immobility and of the irregular distribution of the nutritive
materials which go in excess to the bone before and after repair, ami
in less quantity to the other parts ; now, you are not able to prevent
this irregularity of distribution, which, moreover, is necessary for the
formation of the callus. Irremediable, for I have often prescribed
gymnastic exercises and electrization, and I have not brought the
museles to their original volume. Still it is evident that if anything
can be obtained anil if they wish to try, it is to these two means that
recourse must be had. But you must expect to succeed very imper-
fectly.

II, The second patient is a man, thirty-five years old, who was
treated nearly eighteen months ago, in another hospital, for a simple
fracture of the right leg. He walks very well, and seldom has any
pain, feeling only a little when the weather changes. There is the
same muscular atrophy as in the preceding case. But he has, in the
lower third of his leg, an abnormal bony prominence, which ends in
a point, and still has the form of a V. You know this prominence.
It is that which is so often formed by the upper fragment. It could
not be corrected, undoubtedly because the transversa displacement
was irreducible. Consequently, this patient has a deformity without
functional trouble. The patient, of course, thinks that his fracture
was badly set. Do not believe it, and never criticize your confrires
by attributing this imperfect result to them. Undoubtedly, it might
be due to carelessness, but much more probably to that irreducibility
to which I have already, on different occasions, called your atten-

III. The third patient is forty years old, and had his leg broken
three years ago. He has recovered well; has no projection of the
upper fragment, and since the sixth month, has been able to walk
quite easily, and is free from any articular or tendinous stiffness.
But the tibia has remained voluminous about, above, and below, the
line of fracture. It is not the peripheral callus alone which causes
this excess of volume, as it sometimes does, from the sixth to the
twelfth week after the accident. No, if the callus (the one which
Dupuytren called provisional) baa at any lime been very large, it ia
no longer so to-day, for, as is usual, it has been absorbed. But the
tibia has been bypertrophied, and has remained so since the end of
the treatment, that is to say, the osteitis, which was developed during,
and for the purpose of the consolidation, has surpassed, though we
cannot say why, the limits which were necessary for the formation of
the callus; it has extended to nearly the whole of the shaft, and has
there assumed the characters of hypertrophying osteitis, while about
the fracture it has preserved those of reparatory osteitis. To-day it

■ SIMPLE FRACTCRES OF THE LEG. 127

ia no longer an osteitis, since there are no longer any egntinuoua
pains ; it ia wbat we call hyperostosis, and tViia lesion, which, however,
causes no trouble, is absolutely irremediable.

IV. Fracture cmisoliclaled smce a ymr ago; persistence of neuralgic
paiiis [o-'iteonevrahpti of the tihia). — We have recently seen at our con-
sultation (Piii^, 186e) a woman, 32 years old, whom I treated a year
:)go for a fracture of the left leg below its centre. The displacement
was slight. I first used the Sciiltet apparatus, and then the plaster
bandage. We noticed, during the treatment, more prolonged and
continuous pains than in other patients. She complained every
morning of having slept badly and of having had throbbings and
shooting pains about the fracture. You know that these pains are
very common during the first eight or ten days. You know that,
ordinarily, they grow weaker and weaker, and cease about the twelith
day, or only reappear if the patients move too much or sit up in bed ;
in any case, they are temporary. Well, in this patient the pains
conlinued until the end of the treatment. They appeared without
any previous movement, were almo.st continuous, but became much
worse at night. Furthermore, when I removed the plaster apparatus
on the forty-fifth day, the consolidation was not finished ; I had to
keep the limb immovtibie upon the cushion-trough of which I have
sometimes spoken, and T prescribed from 30,to 60 grains of the phos-
phate of lime daily ; it was only at the end of three months that
abnormal mobility could no longer be found. Ordinarily, this delay
coincides with a painful consolidation I attribute it to this that the
reparatory osteitis ia troubled, and assumes this continuously painful
form with which the slow organization of the callua coincides.

This woman left us a year ago; she walks without crutches, but
with difficulty, and has come to consult us for the pain which she still
feels in the leg. This pain ia much more endurable than it was during
the treatment ; it is moderate while the patient is seated, but becomes
notably intense after she has walked for from twenty to thirty min-
utes. She has then to sit down that it may diminish. Tt reappear.')
sometimes during the night without appreciable cause. The slightest
blow causes fresh intensity.

We examined this leg together. You saw a very regular callus,
and with the exception of a very slight swelling about the fritcture,
to which I cannot give the name of hyperostosis, the conformation ia
excellent. But pressure at this point cause.'^ pain. What is this per-
sistent pain ? I cannot locate it elsewhere than in the tibia, and aa
we have agreed to explain by an osteitis all the anatomo-physiolo-
gical phenomena which occur in the bone after fractures, and during
their consolidation, I have to say that this woman has had an osteitis,
like all those who have had a fracture ; but thnt this osteitis, without
having taken on the suppurative form and without showing any
tendency towards it, has differed from those which we see in similar
cases by the intensity and the continuance of the pain. For a long
time I have made use of the expression, osleiiis of neuralgic form, to
indicate this variety, which we also see sometimes independently of

FRACTUBKa OF THK LIMBS.

fraclurea) and of which it is impossible for me to give you a satis-
factory anatomical or phyeiological explanation.

As for the prognosis, I hope, baaing the hope upon some similar
caaes, that this abnormal sensibility will disappear in time. But will
it need one, two, or three years? I cannot say.

I advised friction with the chloroform liniment, and the use of a
roller bandage or cotton wadding. I have sometimes seen this com-
pression lessen the pain sensibly, and the apparatus has the other
advantage of protecting the limb from those slight shocks which cause
pain, the repetition of which undoubtedly aids to keep up the painful
condition.

This fact reminds me of two analogous ones.

I saw the first in 1»57 and 1858, at the Hflpital Cochin, upon a
mechanic, 41 years old, named Pierre D. His fracture, which was
of the left leg, kept him in the hospital from the 18th September,
1657, until'the 20th March, 1858 (six months). At the end of this
time it was not yet consolidated. The patient, wearied of the hospital,
wished to leave with a new plaster apparatus which I removed three
weeks afterwards, the 8th April, It was then that, finding mobility
no longer, I considered the consolidation made. Seven months, less
ten days, were needed lo obtain this result. Well, during all this
time the patient, who was neither pusillanimous nor a deceiver, did
not cease to complain of daily and nocturnal pains, sometimes with
cramps, sometimes without them, which resisted opium or were only
slightly diminished by it, and of sleep broken by these sufferings.

We might have supposed a deep abscess of the tibia, but there was
none. Nothing in his constitution or antecedents could explain these
rebellious pains ; he was not even nervous. Like the woman pre-
viously mentioned, he had never had syphilis. I questioned and
examined him on this subject a number of times, and obtained a
negative result. Nor was there anything in the wound to explain
the problem. There had been little displacement, and reduction was
very easy. "We remarked only that the fracture had been produced
by direct action. A large wooden gate which he was helping to raise
had slipped, and its edge bad struck his left leg obliquely. But how
many fractures by direct action do we not see recover without this
prolongation of the suffering!

I saw this patient for mors than a year, for he continued to suffer,
less and Jess, it is true, but always very notably, while walking. I
prescribed the rolled cotton dressing, frictions with the chloroform
liniment, and iodide of potassium and valerianate of ammonia inter-
nally. I cannot say that one of these measures was more efiRcacioua
than the others; I only know that little by little the pains diminished.
Since then I have not seen the patient, and suppose that finally the
sensibility disappeared.

The other patient was a lady, 39 years old, impressionable, and
very nervous, who suffered cruelly for three months, during which,
the fracture, a very simple one of the right leg, did not consolidate.
It was only during the course of the fourth month that the mobility
disappeared. Three years have passed since then, and the palietit

fi.i. SIMMONS MEDiauiBRlRY 1

SIMPLE FRACTnRES OP THE LEO. 129

still walks with pain and with the help of a cane. Every movement,
every touch, awakens Buffering, and yet there has been do abscess,
and syphilis cannot be for a moment supposed.

What other name than that of osteitis ofnturalgic form for the first
period of the disease, and osteo-neuralgia for the later period, in which
it is difficult to believe in the persistence of an inflammatory process
in the absence of suppuration and fresh swelling; what other namei
I ask, can we find to indicate these unusual painful forms?

V. Fract'ire consolidated since six months ago ; persistence of painful
arthritis. — This patient is a woman, 58 years old, whom I treated for
simple fracture of both bones of the right leg, in the lower third, six
months ago. Consolidation was neither very painful nor slow. At
the end of two months and a half, the patient left the hospital, unable
to walk without crotches, and evidently suffering in the tibio-taraal
articulation. I then expressed the fear that the arthritis would last
for a long time, that perhaps it would never disappear, for the age of
the patient and the rheumatic pains which she had often felt, made
ma think her arthritis might take on the chronic and incurable form
of the dry arthritis of old people. To-day, six months after the acci-
dent, the lower part of the tibia and the internal malleolus are hyper-
trophied, there is also a notable swelling of the ankle; the spontaneous
movements of the articulation are very limited ; communicated
movements also are limited, cause pain, and are accompanied by
some crackling, There is then, here, a persistent arthritis which
seems to me to belong to the category of dry arthritis. The patient-
will be kept quiet, with soothiug frictions and poultices for two ot
three weeks. I shall also give her some douches and sulphur baths.
We ehali thus obtain an amelioration ; but I do not dare to hope for
an entire cure, which, however, I should consider possible if the
patient were younger. I fear ihat this woman is condemned to walk
always with crutches, and very slowly, and that admission to L»
Salp^tri^re' is the only useful thing we can offer her.

VI. Fracture of the leg cured uiith rotation outwards of the upper frag-
meni {consecutive displacement), — I have again called your attention to,
a patient whom I treated here for a V fracture of the left leg, a simple
fracture, but one which I could not reduce completely, as iodeed
happens quite often in V fractures. I placed the leg in a wire trough,
and established compression all along the upper fragment, except at
its point, where an eschar might have been produced. This patient,
who is only forty years old, still suffers in walking, and as there is a
notable swelling of the ankle, I consider him still affected with the
remains of arthritis " by proximity," which we see after fractures, and
especially after those which have a fissure extending to the articula-
tion, as often happens in the V fracture. I have admitted him to let
him rest for a few days, and to show you a deformity left by the
fracture, deformity which I have seen several times, but which is not
very frequent. When the patient is lying down and is asked to place

's feet side by side, he does it easily, but by turning his thigh and

Ad As/lum for luQiinble and ladi gent Old Womeii.

130

PHACTDRE8 OF THE LIMBS.

knee outwards. If asked to place his kneea in the same position, we
8ee the foot and lower part of the leg turn inwards, that is to say,
consolidation has taken place in this patient, not only with the slight
projection of the upper fragment which you see, but with a rotary
displacement, the upper fragment having turned about its axis from
within outwards, and the lower one, with the foot, frono without
inwards.

This is a deformity, but it causes no trouble in walking. As soon
as he gets rid of his arthritis he will walk, but with hia foot turned
inwards; and after all, when dressed, the defoi'mity will not amount
to much.

It was more than ten years ago that I first noticed this variety of
deformity, which, so far as I know, has not been pointed out by our
authors, and since then I have seen it five or six times,

I should like to be able to tell you what causes it, how it happens,
and how it can be prevented, but I don't know much about it.

The rotary displacement does not exist at the beginning, or if it
does exist, it is so easily corrected that we do not pay much attention
to it. It appears especially in fractures with transverse displacement
of the upper fragment difficult to reduce and to keep reduced. Thus
far, I have seen it only in V fractures. It appears from the eighteenth
to the twenty-fifth day, after the patients have been long under treat-
ment, and all has been done that should have been done, and care
has been taken to place the inner border of the foot and of the patella
in the relations which I have indicated. If the surgeon continues,
while watching the patient, to occupy himself only with the position
of the foot, all seeras to be going on well, but if, at the period of which
I apeak, he compares the position of the foot with that of the patella,
he sees that the latter ia turned outward. He then removes the ap-
paratus to make sure of the fact, and finds that, the foot being kept
in place, it is the upper fragment, and the femur with it, which have
turned oiitwards. It takes place little by little, without pain ; the
patient does not notice it, and when the surgeon discovers it the
effect is irremediable; for it is useless for you to try to correct this
consecutive displacement.

For rae, at least, whatever plan I have tried has failed ; and it is
easy to understand. The consolidation is already too far advanced
to permit the deformity to be corrected. We might make the callus
yield by violent manceuvres, but we might also fail, and even if we
did succeed, the consecutive displacement might be reproduced during
the new consolidation. Perhaps also the exaggerated osteitis thus
produced might cause dangerous suppuration. I have, therefore,
considered it prudent to confine myself to moderate attempts at reduc-
tion, and they have not succeeded.

From the notions which I have given you, you should draw this
conclusion, that, notwithstanding all possible attention, deformities,
which could not be prevented, are possible after fracture of the leg,
and instead of attributing them to the carelessness of the surgeon, aa
non-profeasional people are so prompt to do, we must consider them
due to peculiar and inevitable conditions which our authors have not

FBACTURaS OF THE LEG.

made sufficiently prominent, I shall add this other conclusion, that
we cannot, in these cases of difficult fracturea, give too much care and
watchfulness during the first two or three weeks to the aitaation of
the foot, with reference to that of the patella and knee. Perhaps, if
you recognized this rotation fronn the begiuning, you might remedy
it, at least in part, and be more fortuoate thao I have been, (or thus
far I have only discovered it when it was too late to correct it.

131 ^M

that, ^H
sand ^^H

LECTURE XVII.

FRACTURES (

r. FrHQtore of tlie left leg mora thnu a moDlli old— Obliteration of the r

CoDEolidatloD retarded. Ill, Peeudirtbroaiaivitli augulardisplaceiaenl ; suture I
of tLs tibia ; purulent iuFectioil. ,

I Gentlemen: I. I called your attention during the visit to the
_l1ilieat, in No. 39, who has been treated for more than a month now
in the wire trough for a fracture of the right leg, I could not apply
an immovable apparatus on account of the numerous phlyctenie and
two small superiieia] eschars, the dressing of which required the leg
to be left uncovered. The patient has had considerable osdematoua
swelling of the leg and foot for several days. This swelling, which
occurred without pain, is not very rare in the course of fractures of
the leg. You will find it rather upon adults and old men than in
young people. What does it mean, and what will it become? It
means that the venous circulation is obstructed in consequence of
the coagulation of the blood. I do not think there is thrombosis of
the femoral vein, for I did not feel a hard cord along its course, and
pressure upon it did not cause the pain which is rarely absent in such
a ease. It is rather a thrombosis of the anterior and posterior tibial
veins. We do not here find the pains which spontaneous phlebitis,
with coagulation, often causes ; but this pain is generally absent when
only veins of the second order are involved. We cannot feel tha
hard cord because the veins are too deeply placed to be reached by
our fingers, and the existing oedema increases the difficulty, I can-
not, therefore, prove the existence of the thrombosis by physical
BJgns ; but I admit it because I know it has sometimes been demon-
strated in autopsies after fracture, and also becauael cannot otherwise
explain the cedema. Notice that this is not an inflammatory swelling
of the first period, for the tumefacliou did not appear until towards
the 27th day, long after the inflammatory phenomena had disappeared.
On the other baud, we cannot attribute it to a disease of the liver,
nor of the heart, nor to albuminuria, for the other toot is not (Ede-
matous, and the patient presents no symptoms of these difierent

182 FRACTURES OF THE LIUBS.

diseases. This little complication is instructive From two poiota of
view; first, because the thrombosis will undoubtedlj last a loogtime,
several months; the oedema will increase when the patient begins to
walk, and this swelling will join the other causea, with which yon are
acquainted; rigiditj'of the articuktions and tendons, weakness of
the muscles, to oppose the re-establishment of the functions; second,
because it explains the possibility of the fatal emboli, of which Pro-
feasor Velpeau' and M. Azam, of Bordeaux,' have published cHses,
We ourselves had here, two months ago, a woman who, on the 27lli
day of her treatment for a fracture of the leg, was suddenly taken
with .oppression, precordial pain, and lipothymia, which we attributed
to a pulmonary embolus too small to cause death, but which, if it had
been a little larger, would have completely obstructed the pulmonary
artery and killed the patient promptly.

I wish I could point out, as a complement of these facts, a way to
prevent the detachment and passage toward the heart and pulmonary
artery of clots which I suppose to exist in the tibial veins inflamed
by their proximity to the osteitis of the callus. But I am not ac-
quainted with any prophylactic measures against embolus. That is
_one of those unfortunate complications which the practitioner should
know of, but which, in the present state of our science, he can neither
prevent nor cure when it appears.

II. Delay of the consolidation. — Since I am speaking of the consecu-
tive and tardy phenomena, I want to call your attention to two
patients with broken legs, the consolidation of which is delayed.

One of them. No. 5, Ward St. Vierge, is a young man 23 years
old, who was admitted with a compound fracture. Thanks to the
occlusion which we made with collodion, there was no suppuration,
and then I hoped everything would pass as in a simple fracture ; the
limb was placed in a trough; the patient suftered no pain, but, when
at the end of forty-five days I removed the apparatus, I still found
very marked mobility; the 20th January, two months after the acci-
dent, as the mobility persisted, I applied the immovable apparatus
which is still upon the fractured limb.

The other is a woman in No. 17, Ward Sainte Catherine; her
fracture is more recent than the preceding one, dating from only forty-
five days ago ; however, the mobility and the pains which, from the
beginning, have been greater than usual, still persist and compel us
to use restraining apparatus.

Here are two examples of consolidation that has made but little
progress; but notice, gentlemen, that I do not say non-consolidution,
paeudarthrnsis. For we must not confound a delay with a nou-exiat-
ence of consolidation, and, like Norria, perform operations in cases
which would doubtless have been caused by immobility. As for
myself, I claim that at least a year must elapse before the word
pseud arthrosis is to be pronounced in a fracture of the leg. But to
what can we attribute the delay in our patieots? 1 admit that,"

FRACTURES OF THB LEG.

133

find no canae. Syphilis, sonrvy, pregnancy, nursing, have been
invoked to explain paeudarthroaia; I cannot discover bere the exist-
ence of any of these general causes; and if it is possible for syphilis
to delay consolidation, our patients have not had it. If we examine
the local causes we find, as a possible explanation of the delay, de-
fective fixation of the fragments ; but here iramobility has been too
well maintained for ua to admit this cause. Finally it might be per-
mitted to believe that there is, between the fragments, a piece of
tendon, muscle, or aponeurosis, or a splinter which, by its interposi-
tion, prevents the callus from forming, but that is a thing which we
cannot recognize, and which, indeed, we could not remedy.

"We shall continue then to keep our patients' limbs completely
immovable, and we shall give phosphate of lime internally, to hasten
the formation of a long callus,

III. Anc'enl non-consolidated fracture, or pseudarthrosis, with angular
deformity of the leg; suture of the bones; purulent infection; death. —
Gentlemen, pseudarthroses due to non-conaoUdation of fractures of the'
leg are exceedingly rare. You sometimes hear me speak of delays,
but you have never seen any of our patients remain without con-
solidation. During more than twenty years that I have practised in'
the hospitals of Paris, I have not seen a single one of the fractures of
the leg which I have had to treat, remain in the condition of psaudar-
throsis, I am surprised then to find in Malgaigue's work the statia-
^.ties of an American surgeon, Norris, in which are found —
^P 30 pseudarthroses of the humerus,

^^r 18 " of the femur,

^^C 11 " of the leg and tibia alone,

^^t I wish to put you on your guard against the interpretation which
Bws been given to certain observations in this table, and against th&'
abuse which has been made of operations designed to cure pseudar-
throsis.

The error is due to two causes : first, because, at a certain time, at
the beginning of this century, when the operations of seton and re-
Bection had been proposed, some surgeons in America confounded
delay in consolidation with nonoonaolidatioo, and considered fractures
which still gave mobility during the second or third mouth, as having
passed to the condition of pseudarthroais. Now we know today that
those fractures end by consolidating after four, five, or six months of
treatment. The second cause is that they did not distinguish, among
the pseudarthroses, those which they observed, or thought they ob-
served, in patients who had been regularly treated, and those presented
by patients who had remained without treatment, and whose limba
bad never been set. Now you may be sure, gentleman, that psendar-
throses, not only in the leg, but also in the humerus and femur, are
exceedingly rare in patients who have been properly and peraever-
ingly treated. If we remove from Norria's statistics the patients in
whom they despaired of consolidation too soon, there would remain
only those whose injury had not been treated at all. Now, those are
extremely rare, for generally, fractures of the leg are so painful, that

1S4 FBACTDBE3 OF THE LIMBS.

the patients have to keep quiet, and ao easily recognized that the '
diagnosis must be made, and lead to treatment by immobility.

You may, however, meet with patients who suffer little, and in
whom the diagnosis is rendered difficult by certain anatorao-patholo-
gieal conditions.

I once treated a child, six years old, who had had a fall three weeks
before I was called to see him. At Geneva, where the little patient
then was, the surgeon who was consulted had not detected the frac-
ture, and had allowed the child to walk, which he did with a little
difficulty at first, but al'terwarda quite easily, lie was brought to
Paris, where one day he made a misstep, and felt a new pain in hia
leg (it was the right one). I found, near its middle, a slight swelling,
which I was told had existed since the first fall ; also pain on pressure
at this point, where there was, however, no ecchymoais; and, finally,
after several unsuccessful attempts, I felt very distinetiy a mobility
and a crepitation which left me no doubt as to the existence of a frac-
ture of the tibia, and probably of the tibia alone. I did not doubt
that this fracture had existed since the first fail, and had been consoli-
dated not at all, or so incompletely that the new accident bad caused
the imperfect callus to yield.

Several conditions in children and young people may render diag-
nosis difficult, not only of a fracture of the tibia, but also of a simul-
taneous fracture of the tibia and fibula. The first is the preservation,
at the place of fracture, of the periasteum, which acta aa a means of
union. The second is the toothed disposition, with reciprocal inter-
locking of all the points, and little excavations which correspond to
them upon the other fragment. These two conditions, which, more-
over, may very easily exist together, not only oppose displacement,
but may prevent detection of mobility and crepitation.

In a young man whom I treated in 1865, at La Piti^, and over
whose right leg the wheel of an empty cab had passed, I was unable
at first to recognize a fracture, and after several examinations, I made
the diagnosis, coniusion of the hg. The patient kept the bed because
he suffered while itanding, but he moved as much as he liked in it
It was only on the eighteenth day that, a small abnormal prominence
appearing, I was led to examine it again, and I then felt a fine crepi-
tation and a mobility, indicating a fracture of the tibia which I had
mistaken at first for the reasons I have given. Suppose that in my
little patient and in this latter, at La Piti^, new examinations had not
been made, and they had continued to walk. Undoubtedly, consolida-
tion would have been possible, but it might also have failed and a
pseudarthrosis been established.

This is what probably took place in the young man, 19 years old,
who was admitted into Ward St. Louis, No. 50, the 27th November,
1866. He told us that in December, 18ri4 (he was then 17 years old),
one of his comrades had given him a violent blow with a stick upon
the lower part of hia left leg. He suffered, but did not fall ; was not
obliged to keep his bed, and continued to walk, though limping,
without consulting anybody. He only knows that a small lump
appeared al the place where he bad beeu struck. A month after this

FRACTURES OF THE LEQ.

135 I

tut
nal

tio

icident he fell while trying to jump over a ditch. The eame leg |

,ve him a great deal of pain ; he was carried home, where he kept J

e bed for several days, and then resumed his work in a factory, I

But he could no longer endure the faligue; his leg caused him pain [

after a few hours of walking.

A little later he fell again, and was admitted to the Hotel-Die
'here he remained ten days without anyone speaking to him of frac-

After that he walked with more and more difEculty without I
ling ahle to hear his Toot upon theground; then he saw that his foot '
turned outwards, and that bis leg bent, forming an anterior and inter-
nal angle. This bad conformation was increased by the manipula-
tions of a bone-setter.

To-day we are struck with the deformity of this limb. The foot 1
id the lower part of the leg are turned outwards, and the leg pra- J
Hits, at its anterior and inner portion, an angle, the opening of which I
directed outwards. Grasping

Fig- li-

the leg above and below this
angle, we feel a mobility from
before backwards and trana-
ver.sely which is not very marked,
but which does not allow us to
doubt the existence of an imper-
fectly consolidated fracture, of a
pseudarthrosia with incomplete
vicious callus tor the last «i\.
months the patient has been able
walk only by the help ot i
Wooden leg upon which he rests
ois knee. He declires that he
■ill not remain in this stite ind
^at at any price he viishcs hii
" J to be straightened and si.li h
A ; he his repeated this deul i
ration so often duiing the week
he has been here that I hive de
termined to make an oblique re

^^petion followed by suture of the

^■^o bones.

^HtThe operation was performed in the following way : An incisioa ,

^^DOut three inches long, and parallel to the axis of the limb, was made
along its anterior portion, and crossed by another about two inches
long. The four flaps made by tliese incisions were dissected back-
wards, and the angle formed by the two fragments of the tibia exposed.
I then divided the intermediate fibrous tissue which united the frag-
ments, and, exposing the lower one, I made, with a small saw, an
oblique section downwards and inwards on the inner and posterior
faces of ibis fragment. I then made the upper fragment project, and
made, on its outer face and anterior border, a similarly oblique sec-
tion downwards and inwards, so that, the two sawn surfaces facing
one another, I could bring them exactly together. 1 then rephiced

136 FRACTDRK8 OF THE LIMB

the limb in its proper position, and with much difficulty perforated
the fragments with a drill, and then passed a double silver wire
through the holes, with which I faatened the bonea together. The
limb was then placed in a wire trough with cotton and oiled silk, and
the wound, which was not united, was covered with a simple eerst
dressing.

la short, the operation which you saw me perform was a mixture
of resection and suture. Eesection, without suture, was made in 17(30,
by White, and afterwards by a certain number of English and Ameri-
can surgeons. Then resection, followed by suture, was made in 1825,
by Kearney Rodgers, an American surgeon, and by Flaubert, of
Eoueu, whose two cases were reported by Dr. Laloy.' It is true, that
in all these cases the pseudarthrosis was of the humerus, and in all,
except Flaubert's second, the section was perpendicular to the long
axis of the bone. My operation was peculiar in this, that it was per-
formed for a pseudarthrosis of the tibia, and tliat, conformably to the
precept given by Flaubert after his second case, which was, if I am
not mistaken, a ease of vicious callus, and not of pseudarthrosis, I
made oblique sections in the two fragments in opposite directions, and
united them with a suture.

My patient, unfortunately, was attacked with purulent infection ten
days after the operation, and died the 27th December. I show you
here his lungs and spleen, in which you see numerous metastatic
abscesses. There was also a aero-purulent e&'usion in the two pleural
cavities, suppurative arthritis of the knee above the fracture, and au
abundant suppuration between the fragments, which, though still held
in contact by the suture, are not united by the
callus.

^^ Non- eon

W ""

L HOT USE X7III.

FRACTURES OF THE PATELLA.

eonsoli dated rraotnte of the left patetU, dating rrom 1:
hair inches— SCnrlj cf the n

Gentlemen: I stopped for a long time this morning at No. 25,
Ward Saiute Vierge, to study and to show you the results of an old
fracture of the patella, the frugmenia of which are widely separated
from one another, and do not seem to be united by an intermediate
fibrous substance.

The man, who is 50 years old, tells us that 18 years ago (in 1S50)
he was brought to the same ward for a fracture of the left patella.

Velpeau applied an immovable bandage, with which the patient

' Laloy, Thtees de Paris, 1839. '""

FHACTDBEa OF THE PATELLA, 137

^Mras allowed, he says, to walk after tbe tenth day. He asauref us

H^faat the apparatus remained in place for four months, and thtit when

it waa removed the distanoe hetween the fragments was considerable.

They then applied another apparatus which he cannot very well de-

Bcribe, but which seems to have consisted of two vertical straps fast-

kened, one about the thigh, the other about the leg, with a circular
bandage, and tied together over the patella; they were intended to
beep ihe fragments near one another. This apparatus was removed
fcVery five or six days for about two months, and then, that is, six
months after the accident, the patient left the hospital, walking with
crutches, and with a considerable separation of the fragments.

He spent six months in the country, during which his walking
improved so much that when he returned to Paris he could walk
easily and without a cane, take long walks without being fatigued,
and did not hesitate to resume bis former occupation of bar- tender.

He comes to us to-day for a small contused wound of the right leg,
and would not have spoken of his former fracture, of which he no
longer thinks, if we had not noticed it ourselves.

You noticed a notable deformity of the left knee. Two small bony
prominences appear over it, separated by a long depression. We can
feel that these two prominences are nothing else than the fragments
of an old transverse fracture of the left patella, and by pressing back
the skin over the intermediate depression we can feel the condyles of
ihe femur. Wlien the limb is extended, the separation is two and a
half inches; when bent, it is Eve inches. When the leg is bent, we
can see the outlines of the condyles of the femur under the skin
between the I'ragments.

The patient complains of no pain, and has never had any inflammatl
tion. There is the usual amount of flexion and extension, and iwi ,
abnormal lateral mobility.

We studied the movements, and found that the patient made all of
them easily except those which require tbe almost exclusive inter-
vention of the quadriceps femoris. For example, while he was lying
down, I asked him to flex and extend the knee; he did it quite easily,
but 1 showed you that the extension might be explained by the re-
laxation of the flexors, and the pressure of the heel upon the bed.
To see if he used the quadriceps normally, I asked him to raise the
heel from the bed without previously bending the knee. He was not
able to do it. I then told him to bend the knee and then raise hia
foot from the bed and carry it into the air. He could not do that
either. It is true, that all the muscles of the thigh, and especially the
quadriceps, are less voluminous than those of the opposite side, as iH
the case, I have often told you, with almost all muscles after fractures
But although diminished, these muscles are not paralyzed. You saw
that they hardened during the attempts he made to do what we asked
of him, and that even the lower fragment was drawn up a little. If
the movement of elevation of the foot, in the production of which the
psoas and iliacus aid a little, but for which the action of the quadrii
oeps is absolutely necessary, cannot be executed, it is because thiA

1188

FRACTURES OF THE LIMB

^H action is not sufBciently transmitted to the tibia through the

^H mentum _

^M I then made the patient riaeand walk before ua. He did it withoai

^M the slightest hesitation or limping,

^M While he was standing with his feet together, I asked him to move

^ the left one forwards; he did it, but by flexing the knee. I asked
him several times to bring the foot forward without thus bending the
knee, but he was unable to do so. Why ? Because aa soon aa the
foot is detached by the action of the psoas, iliacus, and adductors, the
knee is held too feebly, and the foot falls either by its own weight or
by the action of the flexors which are not counterbalanced. In I'act,
it is the quadriceps alone which can keep the knee extended whilst

ithe foot is carried forward.
Although the physiological analysis of the functions of the limb
shows us the loss, or at least a great diminution of the contractions of
an important muscle, it is nevertheless true that the patient makes
up for this loss by means of the psoas and adductors, and has no
great difficulty in walking. He mounts staircases quite easily, de-
sueoda them with a little more hesitation, placing both feet upon each
step; can easily walk five miles without a cane, and continues unin-
terruptedly his fatiguing occupation.

The anatomical deformities, or, if you prefer, the morphological
vices ofa fracture of the patella with separation, are here
their greatest degree. I should tell you that you will find aimi
ones in many patients, but to a much less degree.

e often see a smaller separation, of not more than an inch,
example, cause at first functional troubles as great as those of oup
patient, and then gradually the patient becomes able to use his leg
almost as well aa the other. He feels hia infirmity only when de-
scending a staircase, and the surgeon detects the lesion only by telling
the patient to raise his heel from the bed or to move hia foot forward
without bending the knee. These two equally diiBeult movementa
indicate an old fracture of the patella. That is the ordinary result.
Do not forget it, whether the separation is greater or less, the limb ia
neither more nor less weak ; it remains weakened, that is incontesta-
ble, but the patients, except, perhaps, those who have to do heavy
work, do not perceive it, or habit has taught them to counterbalance
the defect of contraction so well, that they pay no more attention to it.
Bear in mind, however, that this proposition, relative to the mode
of cure of transverse fractures of the patella, is not absolute, and does
not apply to all cases.

I establish, like our classic authors, a distinction between fractures
without separation, or a separation of a few lines only, in which part
of the surrounding fibrous tissue remains intact, and fractures with
separation of half an inch or more, in which the fibrous tissue is com-
pletely torn across.

In the first case the fracture heals without separation, and with a
bony callus, and the funutions of the quadriceps are entirely reeai
lished,

FBACTDBES OF THE PATELLA. 139

It is in the second case only thut persistence of the separation is
the rule, that its increase during the first weelcs is not very rare, and
that the cure ia not by a bony callus, A cellular or eeliulo-fibrous
substance is formed between the fragments, and if it is dense it allows
partial transmiasion of the effects of the contraction of the quadriceps
to the ligamentum patellte; but if it ia not denae, and it almost never
is, it does not permit this transmission.

Such ia the rule; but I add at once that exceptions are possible,
and that you may be fortunate enough to obtain, by a well-directed
treatment, or by the existence of favourable organic conditions in your
patient, the exception which we nlwaya seek, that ia, the cure of a
transverse fracture with aeparatiun either by a bony callus, or by a
fibrous one strong enough to permit perfect extension of the limb.

Now two questions naturally arise here. Why these results?
"Why do our methods of treatment succeed only exceptionally in
getting better ones?

1st. Why do we have recovery with separation and a too soft
fibrous callus, or none at all? On account of local and general
causes.

The predominant local cause in the case of an unopposed or unsuc-
cessfully opposed separation, is the communication of the fractured
surfaces with the articulation, and with an articulation which, partici-
pating in the consecutive phlegmasia, fills up with blood and synovia,
and remains full of liquid for several weeks. The materials which
would serve for the formation of a callus fall into this liquid and are
lost in it. This explanation waa Srst given long ago ; you will find
it in all your books, and it ia always true.

A second local cause ia the absence, before and behind the fracture,
of tissues which might help to form thecallua. For I have supposed
that the fibrous tissue, which performs the part of periosteum and
establishes the continuity between the end of the triceps and the
beginning of the ligamentum patellis, is broken. What remains in
front of the patella? Connective tissue and the synovial bursa; but
these tissues, not having been torn, do not undergo the consecutive
inflammation which would enable them to c-sude the materials of the
callus, or if by chance they furnish some, they fall into the articula-
tion, and are not kept between or about the fragments. This absence
of torn tissues, in front of and about the fracture, serves for an answer
to the objections of those who say you attribute the difficulty of con-
solidation to the effusion of the reparatory liquids into the synovial
cavity; how then does it happen that the vertical and transverse
fractures without separation, or with very moderate separation, recover
with a bony callus? The answer is very simple; it ia that there
remains about the fragments in the last two cases a fibroua portion
which keeps them together, which has been sufficiently torn to furniah
reparatory materials, and which serves aa support and gangue to the
callus, which having begun in it extends gradually between the frag-
ments. Furthermore, when the latter remain almost in contact, we
may suppose that the reparatory glutinous subatance of the first days

[cirnish use^^^H

rl40 FRACTURES OF THE LIMBS,

is retained upon tbeir surfaces in sufficieiit quantity to
materials to the callus.
The general causes are inherent to the eonstitution, RememberJ
gentlemen, that thia is a contest between two opposing forces; a ten-
dency to repair, which exists for this bone as for all the others, and
an effort constantly exerted by the tonicity of the quadriceps to keep
up, and even augment the peculiar displacement which exists in this
variety of fracture, displacement by separation through muscular
action. Now, by increasing the separation, the quadriceps elongates
the reparatory suhatance, disarranges it, and opposes ila calcareous
transformation.

Consequently, in fractures with considerable separation, you can
have a bony or a very solid fibrous callus only if tlie surfaces of the
fragments furnish materials capable of being rapidly transformed into
solid substance, and if the muscles will remain inactive for a sufficient
length of time during the treatment which you have instituted. We
' occasionally meet with patients in whom the reparatory tendency is
I sufficiently strong lo furnish a solid intermediate substance during
I the time that we are acting upon the fracture. But we find
whom the intermediate substance has not been able in this time
get the necessary solidity,

2d. Why do not our means of treatment always succeed in pi
I venting this imperfect consolidation ? You know why, if you li _
well understood the preceding details- We do not succeed for three
reasons.

The first is that we find it difficult to bnng the broken surfaces
together, and to successfully oppose the action of the quadriceps.
We sometimes succeed in bringing them into contact with the aid of
certain apparatuses of which I shall speak. But this contact does not
last very long. The qnadriceps ends by slightly overcoming our op-
position. If by chance it does not reproduce the entire separation, it
reproduces it partially ; or the fragments remain together in front,
but separated behind. The second cause is that, in spite of the reten-
tion, the patient instinctively flexes the knee a little on account of
the pain, and thus reproduces some of the separation. The third
reason is that the contention is so exact that the patient sutlers and
loosens the apparatus, thus allowing the separation to again take
place.

All three causes, or only two of them, often act at the same time,
and in any case the same effect is produced, effusion into the articula-
tion and immersion of the reparatory materials in the liquid which it
already contains.

But that is not all; suppose that the mechanical problem has been
solved, and that the fragments have been kept in place by the appa-
ratus which you have chosen. If the consolidation is not complete
when you remove this apparatus, from the 60th to the BOlh day, for
example, the quadriceps will recommence its unfavourable action.
Its tonicity separates the fragments again, the intermediate substance
yields, lengthens, and if the patient moves a little {and how are we to
prevent him from moving after so long a time?), consolidation is^

FRACTURES OF THE PATELLA.

■arrested, and you have a separation with a soft intermediate subatanca^,
■ which amounts to about the same as if you had no intermediate sub-'
JBtance. It is only in young and healthy putients that, during the
■eight or ten weeks of the application of the apparatus, the exudation
|bas the time to organize into a strong fibrous or fibro- calcareous tissue
p-BO solid that the quadriceps can no longer act successfully against it.
and reproduce or increase the separation.

anca^^^^l
sub-^^l

LECTURE XIX.

FBACTUEES OF THE PATELLA.— Cos tin ded.

BX Beoent rraotnre of the patella witli a. aepnratiDii or nearly three- quarters o

inch — Diffloalty of the cure — Indiealioiis to be met — Uiffureiit treatments b; two '
kinds or spparatna ; some closed, otbera open — Prefarenoe gireii to rubbet
lingSi II. Spraiu of the callus, and appamnt relapae a year after a fraetare of
tbe patella.

Gentlemen: I. A man, 35 years old, a carpenter, whom we
I this morning during the visit (Ward Sainte Vierge, 28), caught hi
L foot yesterday morning iu his workshop among some pieces of wood
which were lying on the floor. He fell forward, made a violent eftbrt
to save himself, and then fell backwards, feeling a painful sensation
in his left knee. He was lifted up, and tried to walli, but could only
take a few steps backwards, dragging his leg and leaning upon a
comrade. He was at once brought to the hospital, and this is w' '
we find : —

As physical signs :

Ist, A notable swelling of the knee with a fluctuation that leave(tl
no doubt of the existence of an effusion,

2d, A transverse depression in which the finger can easily
dicating a separation of nearly three-quarters of an inch, and increas-
ing when the knee is bent.

3d. Above and below this depression a bony fragment, each of
which can be easily moved sideways, and is evidently formed by one
of the halves into which the patella has been divided.

As functional signs :

Ist. Moderate pain when the patient does uot move.

2d. Ability to flex the leg upon the thigh.

Sd, Inability to then extend it without using his hands or pressing
his heel forcibly upon the bed and making it slide downwards.

4lh. Utter impossibility of detaching the heel from the bed, and
fcaotable increase of the pain in the knee when he makes the attempt.

^j these signs you all recognize a transverse fracture ef the patella

jF™

W "

142 FKACTUBK3 OF THE LIMB

with a separation wtiuh indicates tbe complete rupture of the fibrous
' isue in front of it.

This fracture has been produced by muscular action, for the patient
fell, not forwards, but upon his back. I ask myself if these indirect
Iracturea, by muscular action, should not be explained by a premature
rarefaction and fragility of the cancellous tissue of the patella ? How-
ever that may be, the lesion is not complicated by a sprain with lateral
mobility, such as I have twice met with in fracture of the patella ; but
it is accompanied by an effusion into the articulation which, consider-
ing tbe rapidity of its production, must be principally formed of the
blood furnished by the patella and the lateral fibrous tissues which
were torn at the same time to a certain extent. But such an ett'usiou
does not take place after a traumatic lesion of the knee without caus-
ing the synovial membrane to inflame and promptly secrete an excess
of synovia which increases the quantity of the effusion. There is
then, together with the fracture, a beginning of the traumatic arthritis
which is inevitable under such circumstances.

What is the prognosis and what will be the consequences of thia
fracture ?

The prognosis is not serious, in this way, that life is not at all en-
dangered, and in all probability the patient will recover the use of
the limb to such an extent that he will be able to stand up, walk,
and gain a living by the trade which he has heretofore exercised.

But the prognosis is bad in this respect, that the injury will compel
the man to remain in bed for about two months, then to walk with
crutches for one or two more, and finally to walk slowly with a cane
for at least as much more. It ia impossible to fix exactly the number
of days, but it will bo very long.

You will hear of patients who, after fracture of the patella, have
remained only four or five weeks in bed, and have been able to walk
without a cane at the end of two months. But those were patients
who had fracture without rupture of the anterior fibrous tissue and
without separation. In naming the approximative limits of the dura-
tion, I recall what I have observed in patients who, lilie this one, had
fracture with considerable separation.

It may even happen that this duration will be longer than I said.
I showed yon that we have here also a traumatic arthritis ; now, this
arthritis may remain painful for a longer time, and compel the patient
to take care of himself and not to worli for six, eight, or ten months.
1 ought to tell you that I have but little fear of this prolongation, for
he is still quite young, healthy, and not rheumatic.

The prognosis is also bad in this way, that the arthritis may pos-
sibly leave behind it an incomplete anchylosis, with very notable
diminution of the movements of the knee, or even a complete anch;
losis,

I had occasion to show here last year, a man, 56 years old,
after a well-managed treatment of a fracture of the patella, recovei
without separation and with, very probably, a bony callus, but witl
almost complete anchylosis of the knee. I should have more fear of
such consequences if our patient was older.

.able
witn

PRACTL^RES OF THE PATELLA.

148 '

Suppose that the concomitant arthritis does not last long and is not
followed by anatomical modifications injurious to the functions of the
limb, the prognosis is still bad, in this sense, that this limb will not
recover the integrity of its functions and the strength which it pre-
viously had. It would recover them if we should be so fortunate as
to obtain either a bony callus or a fibrous one sufficiently short and
solid to transmit the fall effects of the contraction of the quadriceps
to the ligamentura patellie and the leg. Certainly such a result is not
impossible.

I have preserved notes upon 20 patients whom I have treated
during the last fifteen years for fractures of the patella with separation
varying from one-third of an inch to an inch and a quarter, and in
only two of them have I obtained a bony or fibrous callus, solid
enough to allow the heel to be raised from the bed without bending
the knee, and to cause the trausmission to the lower portion of th(
patella of movements communicated to the upper portion, and recip
rocally. And as one of them was twenty-two, and the other twenty'
five years old, I ask myself if youth was not the principal condition
which allowed this fortunate result to be obtained.

In the other:^ recovery took place with considerable separation,
The patients lost their ability to raise the heel from the bed or the
sole from the ground without a previous involuntary bending of the
knee. Their patellre were composed of two pieces which could be
Moved independeutly of each other, and all had the same difSculty I
Kn descending the stairs when the knee was not supported by a knee- 1
«ap. Without that help they could only go from one step to the next ^
i)y placing both feet upon the first and then advancing the uninjured

I fear still more a persistence of the separation when, pressing the
iwo pieces towards one another with my hands, I do not succeed in
bringing them into contact. That is the criterion which I recommend
to you. When with your two hands you can bring the fragments
into contact, there is hope of recovery without separation. This hope
rhaa less foundation when this contact cannot be obtained.

Dr. Lecoin, a former interne at the Vincennes Asylum,' had the

lod idea to record^ the results which he observed during more than
two years upon patients who, after having been treated in the diitereut
wards of the Paris hospitals, had been admitted to the asylum at
Vincennes for their convalescence. These patients were 26 in num-
ber, but as one of them had had an iterative fracture of the same
patella, the author makes the number 27. Well, in 23 of these there
was a separation which varied from one-third to one and two-thirds
of an inch, with independent mobility of each fragment. They had
been treated by various apparatuses, some by the trough and eleva-
tion only, most of them by an immovable apparatus, two by M. Tr^-
lat'a apparatus, one by this apparatus with Verneuii's modification,
one by Laugier'a rubber rings, two by Valette's (of Lyons) apparatus.

> situated outside or Paris, and designed for the recepiion of convalescents ooming
ten the hospitals.
' * Leooln, ThSges de PirU, 186fl, Ho. 248.

[>n ^H

in I

144 FBACTURS3 OF TH

H 14^

^m NotwithatauJing the incontestable advantages of these methods,
^P which I shall explain more fully in a moment, notwithstanding the
* talent and care of the snrjfeons, the separation persisted with an im-
perfect consolidation which left the patients in conditions nearly the
same as those of non-consolidation.

As for the other four, they are given as recoveries with a bony
callus. But the author could not learn in each case whether the frac-
ture had been originally with or without separation. In one of them
alone was it known that M, Cusco had made the diagnosis of fracture
without separation, a fact which easily accounts for that callus being
favourable.

On this point we know nothing in the other three. I will admit
that all of them owed their bony callus to succeasfnl treatment of a
fracture with notable separation; we should thus have three good
results out of twenty-six, a proportion similar to mine (two good
results out of twenty).

Can we obtain a better proportion? Ibelieveso; but the proof
is yet to be given.

Malgaigrie' perhaps darkened a little the list of the inconveniences
left by fracture of the patella which was henled with separation.
Undoubtedly the limb remains weakened, in this sense, that the eon-
tractions of the quadriceps are no longer utilized except by means of
the transmission of their effect through the fibrous tissues on each
side of the patella, and by an elongated patella, the movable upper
fragment of which consumes most of the effort wiiich is communicated
to it, and transmits but a very small part to the lower fragment.

We must also take into account the muscular diminution which I
have often mentioned when speaking of fractures of the thigh and
' ig, and of which I showed you an example in a patient affected with
n ancient fracture of the patella. But, nevertheless, most of the pa-
tients, all those who have retained neither arthritis nor anchylosis,
and who suffer only the consequences relating to the quadriceps, be-
come able to walk verv easily without a cane, to take long walks
without fatigue, and, in short, to no longer notice their fracture or
the weakness of the limb, except when they go up, and especially
when they come down staircases. Perhaps Malgaigne, in the estimate
which he made of the results, did not sufficiently distinguish between
that which was the consequence of the arthritis, and that which was
the consequence of the weakening of the triceps, which was undoubt-
edly because he examined the patients too soon after the accident.

ITo exactly appreciate the consequences of a fracture of the patella
they should be studied several years after the accident, and after being
satisfied that the arthritis has left no had result.
I must now mention another unfortunate element of the prognosis.
The patient may perhaps break the other patella, and break it in the
same way, by muscular action, and with separation of the fragments.
I have seen an example of this, as have also Malgaigne,' Demarquay,^

• MalgBigne, JonrtiaUie CliirufEie, t. ler, p. 201 ; and Trails dea Fraoluras, p. 7511
' Uomarquay, GazittB daa llflpilft ' """

* Malgaijjue, tIazHtte dea UApitaa

™ FRACTURES OF THE PATELLA. liSl

and M. Tr^lat,' Now, if tlie second fracture sboulil give tlie sameL
results as the first, tlie patient would be really infirm. With on^J
bad patella and a good one upon the opposite side, the functions art
well enough re-established, aa I told you; but with two bad patellasjj
the weakness is very much greater. The walk is uncertain, needa^
artificial support, and cannot be long continued.

The patient whom I treated in 1869, and who is now forty veal's
old, had had his right patella fractured nine years before. There
remained, after treatment by the dextrine bandage, a separation of
from one to one and a half inches, and very little or no intermediate J
fibrous substance. The left patella was broken in June, 1869, in.
consequence of a mis-atep and a fall backwards. The separation waUi
more than three-quarters of an inch before the treatment. At th^
end of a fortnight we treated him, Dr. Philippeaux and I, by r
of an apparatus invented by the former which resembled in some I
points Fontan's and Vallette's. The fragments were kept almost ia; J
contact, but the pressure occasioned sometimes so much pain, espe-^
cially at night, that the patient turned the screw and allowed ihefi
separation to be reproduced, tightening it up again the next dayj
This apparatus remained in place for seventy-eight days, at the end oW
which time we removed it, hoping that the intermediate substance had I
become solid. The patient remained in bed fifteen days longer withd
the leg raised upon an inclined plane; commenced to sit up on the '
ninety-third day, and to walk with crutches, still without bending
the knee, on the one-hundredth day. Little by little the fragments
separated by the lengthening of the intermediate substance which
was too soft to resist the action of the quadriceps. This separation
finally amounted to one and a quarter inches, the patient could walk j
only with a cane and slowly, go up and down stairs with difficulty, and ]
could not take long walks.

These consecutive fractures of the patella are not so frequent thai
we are authorized to believe them due to a peculiar predisposition I
of the subject, or to the insecurity of the walk, and the exposure i
to falls after the first fracture, rather than to chance. But in any
case there is no harm in remembering the possibility of the fact in
making the prognosis and in choosing the method of treatment.

IVeaimenL — How shall we treat this patient?

We have to distinguish two periods: a first, of from Sftee
twenty days, during which we have to occupy ourselves only with
the arthritis and articular effusion; and a second, during which, the
inflammation having gone down and the effusion having diminished
or disappeared, we may think of some apparatus for bringing the i
fragments into contact.

1st. For the first period, the patient will be kept in bed with his

foot raised as high as possible, so as to relax the quadriceps femoris;

for that purpose we might use simply large cushions of chafl'. But

tj these cushions it is probable that the knee would soon flex a little.

I resisting surface, to prevent, or at least to greatly diminish this

■ Trflftt, gaietta de a Hflpitoni, IBflB, p. 623.

146 FRACTURES OF THE LIMB

^B flexion, ia necessary. We might follow the example of Grerdj, and

^1 place a chair in the bed, so that its back, covered with a cushion,

^M^ could support the leg. I have sometimes used this, and would do ao

^B" again if I did not have other means at my disposal. I gave it up

^P because the chair lakes up too much room and troubles the patient,

and also because it happens quite often that the heel sinks into the

interval between two of the rungs so as to produce the flexion of the

knee which we are seeking to avoid. Still the limb might be placed

I in a trough and then rested on the back of the chair.
Desault recommended a long posterior splint and an appropriate
ousliion. This splint extended from the middle of,the thigh to beyond
the foot ; a long cushion of chaff was interposed between it and the
skin, and it was kept in place by a roller bandage. But this bandage
has the double disadvantage of getting loose loo soon, which permits
a lateral displacement of the splint and consequently a flexion of the
knee, and of masking the injured region. This might be avoided by
fi.\ing the splint with three long bands of diachylon rolled about the
thigh and the upper and lower parts of the leg. But diachylon easHy
irritates the skin and causes erythema with itching, and for that reason
I do not like to use it.
I prefer an inclined plane, made like a trough, which I have made
by any carpenter, to suit the size of the patient and the dimensions of
the limb, Our patient will be placed upon a plane of this kind, by
which the knee will be kept extended and the quadriceps relaxed.
Poultices sprinkled with lead-water will be placed every morning and
evening upon the keee. As the articulation is greatly distended bj

»the effusion, we may be tempted to make a puncture, as Professor
Jarjavay recommended and did several times for traumatic effusions
in the knee without fracture, I have not thus far been a partisan of
his operation, for here the inflammation is more intense than in
simple contusions, and there would be reason to fear that puncture
might cause it to become suppurative. Now, suppuration of this large
articulation is too dangerous for us to expose the patient to it.
^L 2d. For the second, I shall have to choose between two methods of

^M treatment: simple elevation, or a uniting apparatus.
^M I understand perfectly that surgeons, who, like myself, have been

^M struck with ihe rarity of recoveries without separation, have proposed
^M to treat fracture of the patella by simple elevation of the limb. This
^P is the advice which Valentin' and Sabatier" gave.
^^ I would willingly adopt this method, which has the advantage of

^1 avoiding the constrictions and painl'ul pressures of most bandages, if
^B I could be sure of curing my patient without separation. But from
^H what I have already told you, we have at least one chance in eight
^m or ten of obtaining, by means of a uniting apparatus, a better result,
^H that is to say, a very short and solid intermediate substance, and
^H consequently a more prompt recovery and a complete restoration of
^M the functions of the limb. It is all the wiser to take this ohaj

FRACTURKS OF TJIK PATELLA. 14'

because we can reduce tbe pain to almost nothing by multiplying iho'
precautions and care.

It now remans to chooae a uniting apparatus.

A great many have been invented, I counted fifty from an inter-
esting memoir by Dr. B^renger F^raud.' Do not wonder at thiai
abundance, gentlemen ; it is espluined by the difficulty which has
always existed to obtain a -good result, and by the eagerness to
explain this difficulty by the insufficiency of the treatment; whereas
a large, the largest, part should be attributed to the anatomical and
physiological conditions of which I have spoken, and which no
apparatus can completely suppress. The uniting means meet satis-
factorily one important indication, that of bringing the fragments
together and overcoming the action of the triceps; but while doing
it the? produce pain which causes the knee to bend instinctively, and
thus re-establishea a certain degree of separation, which is one of the
causes of non-consolidation. And then, whatever may be the patience
of the patient, the apparatus cannot be kept long enough in place for
tbe intermediate substance, at the time of its removal, to be solid,
ongh to resist the traction exerted by the quadriceps. We aucceedj.
I told you, only when the subject is one of the few in which this^
iJidity is promptly acquired.

Which one shall we choose?

I- I leave out first all completely closed bands which hide the
region from view, and I advise you not to use them unless you find
yourselves absolutely unable to procure the rather more complicated
means of which I am about to speak. For whether it is a roller
bandage with a double headed compress above the patella, and another
one below perforated to receive the ends of the upper one, thi
bandage which you know under the name of the uniting handage
Irtmsverse wounds, or whether it is a roller bandage with crossi
compresses placed above the upper fragment and below the lower
one, you will always have this disadvantage, that if you do not
tighten sufficiently over the knee the fragments will not be brought''
.Dear enough together, and if you do tighten sufficiently you will
ive a painful compression. Oil the other hand, the apparatus soon
asens and the displacement is reproduced. It is in vain that yofl
mew it every day or every second day; if you have taken care, by
laking it only moderately tight, not to' cause pain, you allow the
_ iparation to be reproduced to a certain extent. Of course, if the
roller bandages are used they must be accompanied by Desault's
posterior splint and elevation of the limb. These two adjuncts correct
the insufficiency of the method tiy at least relaxing the quadriceps.
and extending the knee.

Immovable closed apparatuses, made with dextrine, plaster, or
silicate of potash, and applied about tbe fifteenth or twentieth day,
when the articular swelling has gone down, have been much employed
recently. These bandages are inferior to tbe preceding ones for the
'lUowing reasons: during the first few days they keep tbe fragments

} Bfranger-Ffraad, Eevae de Tlifirapeutique Medico-ohirargicale, ISGb, p. 481.

]

.148

FRACTURES OF THE LIMBS.

^H well together, then ihey grow loose because the compression dimm-
^1 iahes the volume of the muscles, and as soon as this diminution corn-
el mencea the upper fragment is drawn upwards bj the quadriceps. If
^H you employ an immovable bandage do not forget to place a. posterior
^H splint between its layers and keep the foot elevated.
^H I give the preference to open uniting apparatuses, that is to say, to
^H those which leaving the patella uncovered enable us to see if the
^1 separation is corrected or not, if the akin is excoriated, and to modify
^f the situation of the pieces according to the results of this examination.
These apparatuses are of recent invention, and will meet the indica-
tion of bringing the fragments together. But I establish a distinction
between those whiuh have to be made by a workman, and those which

I the surgeon can easily make himself.
In the large cities this distinction is of little use, since we can easily
obtain the things we need; but it is not so in the country. Of course
if fractures of the patella were frequent we might always have at our
disposal one or the other of the uniting instruments which I am about
to mention. But these fractures are rare; a busy practitioner will
hardly see two a year, many will not see more than one or two in
three years. Now it would always happen, if you kept the instru-
ment on hand, that it would be rusty and would not work when you
had need of it. Undoubtedly the remedy would be easy, for you
would always have the time to have it repaired, or even to have a
new one made during the fifteen or twenty days of the inflammatory
period; but what is the use of having this trouble if these manufac-
tured apparatuses do not give any better results than those which you
make yourself? And that is just what happens.

I. Among the uniting instruments I will mention Malgaigne'a
, hooks, the modification in their use proposed by M. U. Tr^lat, Val-
^_ lette's instrument, and Fontan'a.

^^ 1st. Malgaigue's hooks (Fig. 12) which I now show you, and
^H which it is sufficient to see to understand, are composed of two pieces
^f which can be moved along one another

\^ Fig- 12. by means of a screw. Each piece

ends in two hooks which are implanted
above and below the fragments, tra-
versing the tendon of the quadriceps
and the ligamentum patellEe. After
having been properly implanted, the
two pieces are brought nearer by
means of the screw and thus the frag-
If the patient sutlers too much it is loosened;
leparation ia reproduced, it is again tightened,
advise you to use this instrument I should enter
into longer details upon the manner of applying it, upon the difficulty
of properly implanting the upper hooks, upon the considerable eftbrt
which ia needed to do so, upon the pain of the first hours, upon the
tolerance which is afterwards established, upon the possibility of
phlegmonous and consecutive lymphangitis, of which I have had aa

ments are held togf
if, after a few days,
If I intended to i

^^nd

FEACTURKa OF THE PATKLLA.

mple, aad even upon that of an artliritis, like the one which I
ind reported in the Union Aledicale.^

But I do not dwell upon it for two reasons.

First, the books, as applied by Malgaigne, because thej traverse
the skin offered many disadvantages, and were very disagreeable tO'
the patients; they could not remain in place long enough for the
GODSolidation to take place. They were applied on the fifteenth or
twentieth day, and had to be removed by the fiftieth, and often
sooner, because they held no longer; now at this period, aa I have
told you, the intermediate Bubstance is not solid except in very excep-
tional cases. Consequently this gives the patient pain and annoyani
without any profit.

Secondly, if you wish to use the hooks, you can now do so withoot
traversing the skin, thus suppreaaing most of the disadvantages of
Malgaigne's original method. For this we use Prof. TriSlat's modifi-
cations.

2d. M. U. Treiat's Melhod? — Dipin boiling watertwopiecesof gutta-
percha five inches long, two and a half inches wide at one end and
one and a quarter at the other. Apply one of them above, the other-
below the patella, modelling ttiera exactly upon the anterior and
lateral faces of the limb and upon the patella while the leg is com.
pletely extended. Tben apply compresses dipped in cold watei

Fig. 13.

ich iH

versa ^H
le tO'^H

r the ^H

^Vil

the gutta-percha, and when it has lost its softness plunge i
into a tiasin of cold water. Then while an assistant holds the frag-
ments together, the surgeon places one of these pieces above the upper
fraginenl, and fastens it there with a atrip of diachylon long enough
go thrice around the limb. The same is done for the lower frag- J
mt. It only remains to implant the hooks in each of these plates I
thoot going through to the skin, and to screw together the two *
pieces of the inatrnment, thus bringing together the two pieces of the
patella near to one another.

It cannot be denied that this modification is ingenious, but is it

■ tJoloa MedioHlH, 18 Dec

■ Tr«l>t, NotciBur leTrni
^Uetin TLfirapputiqiio, 11

ilier, 1871.

neDtdeB Kr^tctvires de

\, tome Ixiii. p. -147).

I Rolule par uu Nouvel Apparoil

VlSO

^M not a
^ fragiT

FRACTURES OF THE LIMBS.

not also a little illusory? Does not the upper plate slide over the
fragment without pushing it along? Is there no reason to fear that
the hard gutta-percha may cause excoriations and eschars? I feared
so, aod for that reason I have not used it. It ia true that I was also
turned from it by the preference which I gave to apparatuses made
with vulcanized India-rubber, which had been proposed at about the
same time, and which seemed to me to offer more security.

'6d. Fenitan'a Apparatus {V\g.li), and Vallelle's [of Lyons) (Fig. 15).—
I shall show you these without describing them. They are more
complicated than the preceding ones, but both of them meet very
well the main indication. Vallette's has the disadvantage of breaking
the skin. Fontau's does not do that, but by the pressure it exerts it
may cause eschars, consequently it needs to be carefully watcl
especially when the skin is fine and thin, as in women.

Fig. 14.

In my opinion these are not superior to Malgaigne's and Tr^Iat's,
and they are inferior to those of Morel-Lavallee and Laugier; and
, therefore I have not used them and advise you also not to.

II. Among the uniting apparatuses which leave the patella uncov-

I ered and which the surgeon can make for himself, I first mention

1 Mayor's;' which consisted of a wire trough upon the sides of which

were attached four non-elastic well-padded bands, two above and two

' Ma^or^ Qaiette H«di(>ale, gp. 184.

FBACTURKS OP THE PATELLA

1511

below the kuee. The limb being placed in the trough, the two upper
bands are brought over and crossed above the upper edge of the
patella and tied together on the aide, and the two lower ones are
crosaed below the lower edge- The bands, thus tightened, ought to
keep the fragments together. But to make it still yurer three ribbons
are sewed to each of the transverse bands and tied together, each
upper one with a lower one, so as to draw the tranaverae bands nearer
together, and with them the fragments. Morel ■ La vallt^e's apparatus,
well described by M, Bosia,' differs from Mayor's in this, that the trans-
verse bands above and below the patella are made of India-rubber
webbing, like that of suspenders, and that these bands, instead of
crossing above and below the patella, cross on the edge and, at the
same time, the anterior face of the fragments, so as to prevent them
from tipping. Their action is also completed by the same vertical
bands.

4th. Laugier's Method: Oblique pressure hij means of two rubber
migs. — In the two preceding apparatuses the fragments were kept
in place by pressure perpendiealar to the axis of the limb, applied
above and below the patella, and by parallel pressure. Professor
Laugier* had the idea of using two vulcanized rubber rings which,
placed obliquely, would press, by their elasticity alone, each fragment
towards the other. The apparatus (Fig. 16) is arranged in the
following way: —

The limb is placed upon a board covered with a thick cushion,
'he board and the cushion reach an inch or two beyond the leg on
ide. Two cross-pieces are fastened to the bonrd, one of them
three inches above, the other three inches below the patella. The
board itself lies upon a cushion aa long as the leg, the lower end of
which is much higher than the other. The limb is placed upon the
itiahion, and two pieces of gutta-percha, after having been dipped
[tato boiling water, are moulded upon the upper and lower ends of the
itella. Then one of the rubber rings, in the form of a flat ribbon,
over the leg and the board and stretched from the lower
cross-piece to the piece of gutta-percha which is over the upper frag-
ment of the patella. The other ring is stretched from the upper

■ Bnsia, GnzHtte des BapilinK, ISGO, p. 413.

* TbiB appuratua Una been deaoribed by U. Qanjol (Arasual de la ruirol^En Cnn-

mporaiiie, tuiue ler, p. 24(i), and by M. Dubiuuil (Gazette dui Hclpitaax}, 18(19^

FRACTL-RE3 OF THE LIMBS.

^H cross-piece to tbe lower fragment. As the rings have to be stretched
^H to mke this position, their elasticity tends to draw the pieces of gatta-
^H percha and, through them, the fragmeiita together.
^^ I have used this apparatus twice; but fearing lest the hard gutta-
^H percha might cause pain, excoriate the skin, and produce eschars, I
^^ substituted for it two cotton pads. In one case the result was excel-
lent. In the other the separation reappeared when the apparatus,
which had remained in place for forty-five days, was removed. In
both patients I found that the pressure was sometimes very painful,
and I had to allow thetn to remove the rings for a few moments and
then replace them, I also found that the pressure was not sufficient,
, and I had to put more cotton under the rings to bring the fragments

together.

To remedy these disadvantages, and to give the limb a greater and
more certiiin elevation, I modified Laugier'a method, for a private
patient, in the following manner: —

I had the strong inclined plane, of which I have already spoken,
made by a neighbouring carpenter, and had six hooks placed on each
Bide, three turned towards the thigh, three towards the foot. I then
.made two rolls of cotton enveloped in coarse cloth, and sewed loosely
on them two tubes of very elastic vulcanized rubber, to each end of
which was tied a stout string. The limb being laid upon the inclined
plane, I placed one of these rolls over the upper fragment, and while
an assistant pressed the latter as near to the other fragment as possible,
I stretched the tube by drawing on the strings and then fastened
them to one of the lower hooks. I then placed the other roil below
the lower fragment and fastened its strings to the upper hooks.

By this means I could modify the pressure at will, increase it
when I found separation, and diminish it, without removing it entirely,
when the pain was too great. After a few days I found that, notwith-
standing the great pressure, the separation reappeared and the frag-
ments tended to tip upwards. I then completed the apparatus by
passing two elastic tubes longitudinally in front of the patella and
hooking them to the oblique ones. In this way the fragments were
kept exactly together. But I often had to yield to the entreaties of
tbe patient, who suffered very much, and allow the vertical tubes to
be removed for several hours at a time and replaced as soon aa the
pain was over.

Pain and eschars are always to be feared with these apparatuses, as
with all those that exert a strong and steady pressure upon the same
surface. It thus becomes necessary to watch carefully and to loosen
ihe cords whenever the pain becomes great and the skin reddens.
This last patient, who was a young man of 23 years, is one of those
in whom I think I obtained bony consolidation. At the end of sixty
days he walked without a cane, descended the staircases easily, and,
when lying down or standing, could raise his foot without bending
the knee. The separation, which at the beginning of the treatment
was three-quarters of an inch, was only about one-eighth of an inch,
and the substance which filled it was so solid that transverse move-

IP"

FRACTDBES OF THE PATELLA, 153 J

ments eommunicated to the upper part of the patella were easily trans-
mitted to the lower part.

In short, the two best results which I have obtained in treatment
of fractures of the patella with separation, I have owed to apparatuses
in which vulcanized rubber played the principal part, and that is
why I give it the preference. Before that I had often used bands ■]
dipped ill collodion.

I do not refuse to admit that other methods might give equally
good results, bat it seems to rae that with vulcanized rubber, which.]
can be so easily procured, the apparatuses have a simplicity of con*
struction which should cause their adoption by every one.

In any case, do not forget, gentlemen, that, whatever may be thft-
mode of treatment, recovery with separation will always be tha
exception, because the quadriceps will most often end by overcoming
the still insufficient resistance of the intermediate substance, as soon
as the six or eight weeks, beyond which it is very difficult to have
the treatment borne, have passed, and the fragments have to be ' " '
themselves.

To recapitulate, the treatment of our patient will be directed na-
follows : —

For about a fortnight T shall keep the foot elevated and apply
poultices; during the following thirty days I shall use the bandage
of vulcanized rubber; after which, still keeping the patient in bed
and the foot raised, I shall see if the fragments separate. If they do
not separate, I shall try to keep him in bed until the sixtieth day.
If they do separate, I shall propose to the patient to apply the rubber
bands for another month, which would give us in all eighty or ninety
days of confinement to the bed, and in case he should not willingly
accept the proposition, I should not urge it very strongly, for I am
not at all certain that consolidation of this bone, if not obtained in
forty-five days, can be obtained in sixty-five. Still, the attempt may
be made.

After this period of confinement to the bed, the duration of which
I cannot previously determine, I shall allow the patient to get up,
and give him crutches.

I shall then occupy myself with the stiffness oF the knee; if it IB
very great, I shall order moderate movements of flexion and extension
to be made every morning and evening, and shall advise the patient
himself to make some; in addition I shall prescribe massage and
sulphur douches. If it is not very great, I shall tell the patient '
execute movements of flexion himself, but with moderation.

There is one danger here which you foresee and which must be
avoided. The intermediate substance, whatever its length and resist-
ance, must be very carefully treated at this time, Already drawn
upon by the tonicity alone or by the voluntary contractions of the
triceps, it would be still more so by a flexion carried a little too far.
Care must then be taken not to go beyond a moderate limit.

Then, when, fifteen or twenty days later, walking becomes a little
easier, is possible, for example, with a cane, I shall advise the patient
to support the knee while walking with a small roller bandage cover-

I
I

154 FRACTURES OF THE LIM

ing tte lower tliirtt of the thigh and the upper third oFthe leg, and
containing a posterior wooden splint. This dressing is intended to
prevent a too great involuntary flexion, whiuh might cause rupture
of the intermediate substance or renew the arthritis ; it is also intended
to make walking easier and to allow h little beneficial exercise, and
ia to be worn only while the patient is walking.

This precaution will be taken for only five or six weeks \t we find
that the intermediate substance is solid, and if the separation has not
increased. After that I shall prescribe the use of a rubber knee-cap
during the day.

On the other hand, in case the separation should increase, and the
knee, notwithstanding the disappearance of the arthritis, should
remain very weak, the patient miglit use one of the more complicated
knee caps which by an arrangement of elastics or springs assist the
action of the quadriceps, or may even supply ita place entirely.

Whichever may be the apparatus used, you may be sure that after
a few months it will be no longer necessary, and the knee will have
recovered enough strength and solidity to no longer need any help.

III. Sprain of ike callus and appearnnce of relapse in a patient who
had a/racture of the right patella a year a^o. — Here, gentlemen, is a
woman whom I treated a year ago for fracture of the right patella,
with bands dipped in collodion.

There remained, in spite of all my care, a separation of three-fifths
of an inch, independent mobility of the fragments, and inability to
raise the foot from the ground while keeping the knee extended.
Flexion of the knee had not recovered its full extent, not going be-
yond a right-angle ; nevertheless walking was easy, and I had advised
the patient to wear a kneecap, but she had soon neglected its use,
YesterLlay she made a mis step, fell, and felt a slight crack and
pain in the knee; she was, however, able to take a few steps, and
then, thinking she had again broken the patella, she had herself taken
to the hospital.

You may have noticed an ecchymosis on the anterior and inner
portion of the right knee, and a very moderate swelling without
appreciable effusion in the articulation. Movements are painful;
flexion and extension are possible however, but the foot cannot be
raised from the bed.

Let us not here commit the error which I have sometimes seen
committed, that of believing in a complete rupture of the intermediate
fibrous substance, and the reproduction of a fracture, and thence
conclude that the patient ought to be subjected to a treatment of two
or three months in order to re-establish the broken callus.

Instead of an iterative fracture this is simply a sprain with very
■ limited rupture of the new tissue which unites the fragments, and it
is because the bloodvessels of this tissue are numerous and fragile
that a considerable ecchymosis has been produced by a very limited
fibrous rupture, I say that this rupture is not complete, and even
that it ia very small, because the separation is not greater than when I
last examined the patient, and because I still feel between the frag-
ments a certain thickness of tissue which prevents my touching the
coDiljles of the femur.

SIMPLE FRACTURES OF THE SHAFT OP THE FEMUR. , 155

I also base the opinion upon two analogous cases, both in women,,!
which the physicians first consulted supposed to be iterative fractures. T
As I had treated the cases fifteen months before, and as I found the
parts in the same anatomical uondition in which I had left them, I
declared that it was only a sprain, and that the patients would be
able to walk in a day or two, just as before the accident. The events .
justified the prediction, J

In the present patient the lesion is the same, sprain of the fibrous I
callus, probably rather vascular, of the patella. The patient will "
remain three or four days in bed with poultices sprinkled with spirits
of camphor, then she will replace her knee-cap and be able to walk.

Tbe ecchyniosis will gradually disappear, and furnishes no special
, indication.

1 SIMPLE FRACTURES OF THE SHAFT OF THE FEMDR. . ^^H

Rmple fracture of tbe Bhaft of the remnr — Cominetnorativea— Attitnde of the patlentB ^^^|

-Defonnitj — Appnrent shortening, real shorteuing — Abnoriua] moLllitf — Doable
mttnieaTre to settk it — Crepitation — Exact point of the fr&cture—CouaeoutiTe
arlbritia of the kuea, of the hip-joint — Orerlappiug irredacible bj the bands and
flimpls bnudagee — Employment of chlovofoi'm — Saiiltet appara.tn9— Continnou
estenaion— Reaaoua nhy it ia not generallj used in practice, ita utility i:
oortain qbshb — Preference given to Benueqniu's apparatus.

Gentlemen : We have at this moment in the wards several patients j
affected with fracture of the shaft of the femur. I take the oppor-
tu[iity to show you the peculiarities presented by this lesion, which ig
quite common in practice.

I take OS types the patients lying in Nos. 5, 11, and 46. All three J
represent their injury as caused by external violence. The first was I
run over by an omnibus, the others fell from a high place. Only J
one of them heard a crack at the time of the accident; the other two j
do not remember the eireumatances of their fall. Neither was able I
to rise after the accident, and all were brought to the hospital by their f
comrades on stretchers.

You saw them lying in their beds, each one on his back and a j
little on one side, and they have kept that position since they were j
admitted; it is the one in which they suffer least. Raising the bed-
clothing, we see a slight bending of the body, towards the right sida I
in No. 5, towards the left side in the others, I told them to lie
straighter, squarely upon the back ; they were not able to do so^
and the attempts which they made caused much pain. I asked them
to raise the heel of the injured limb from the bed. This attempt also
remained unsuccessful and caused renewed pain, while the uninjured
limb executed tbe little manoeuvre perfectly,

15t( , FRACTURES OF THE LIMB9.

You noticed bow the shape of the iDJured thigh differed from that
if the other one, how it is gathered up and twisted aboal its axis.
You also saw that the foot, as well as the leg, lay on its outer aide.
~ere then are two signs of fracture: deformity, and outward rotation
of the limb.

On a gnperfioial examination our eyes detect ouly a slight shorten-
ng; but if we stretch a string from the spine of one ilium to tliat of
the other, we sea that its direction is oblique with reference to the
axis of the body, and that the iliac spine on the injured aide is sensibly
lowered, whence we conclude that, although the shortening seems
slight, it is really greater than it seems.

Then stretching the string from the anterior-superior spine of the
ilium to the external tuberosity of the femur, and then to the external
malleolus, and then making the same measurements upon the other
side, we find that the injured limb of No. 5 is shortened at least an
inch and a quarter; then measuring both limbs from the spine of the
ilium to the internal malleolus, we find the same difterence; there is
then a very considerable real shortening, and as the patient assures us
that he did not limp before his accident, this sign has a great value.

I then sought for abnormal mobility by two manoeuvres. You
saw that one consisted in raising the heel and the leg with one band
whilst the other was placed transversely over the middle and anterior
portion of the thigh. Then giving a lateral movement to the limb
with the first hand, I saw that the lower part of the thigh moved
with the leg, while the upper part remained immovable, and I felt
with my second hand that no movement which might have escaped
detection by my eyes was transmitted to the upper part, and that the
hinge or centre of movement of the movable part was a little below
the middle of the femur. The same manceuvre executed upon No. 11
showed us that his fracture was situated at the centre of the bone,
and in No. 46 the femur was broken high up, just below the great
trochanter (Malgaigne'a snb-trocbanteric fracture).

To seek mobility by the second manceuvre, I passed my band, by
depressing the- bed, under the injured thigh, and then raised it a little.
By this movement the thigh was bent at the point of fracture, forming
a projecting angle in front, while the same experiment repeated upon
the uninjured leg did not give this result.

During these two manceuvree I bad also felt crepitation. I am
therefore perfectly sure of the lesion; our patients have fractures of
the thigh, and it is not necessary to prolong the examination to make
the diagnosis.

Our three patients have presented the same symptoms; but the
prominence formed by ihe overriding of the two fragments of the femur
seemed to us much higher in No. H than in No. 5, and much higher
sLill in No. 46. In all the pain is greatest over the point of this promi-
nence.

I have called your attention especially to the deformity of the

thigh; but the knee also is increased in size. It is appreciable by

the eye and by direct measurement. Passing a string around the

P condyles of the femur and the middle of the patella, I fiud that in one

I SIMPLE FRACTURES OF THE SHAFT OF THJt FSMCR, l5t^^M
fttient the circumference of the knee upon the injured side is twOri^^H
ftha of an inch greater thun on the other, and in the other t'W> j^|

patients the difl'erence ia three-fiflhs. Suspecting the presence of
liquid in the articulation I grasped both ita sides with my left hand,
a little above, and with my right hand, a little below the patella,
and then without changing ihe position of the handa I brought my
right index finger upon the centre of the patella which yielded under
the pressure and was forced backwards against the condyles of the
femur. During this manoeuvre I distinctly felt the other fingers
raised up, which could be due only to the presence of liquid. Our
three patients then have a considerable effusion within the knee-joint,
and it is greatest in the one, No, 5, whose fracture ia the lowest.
J'erhaps you think that this lesion is due to a concomitant coatusion
pf the knee produced by the violence which caused the fracture.
p It ia not so ; first, you find upon their knees no sign of a contusion,
«Qd then, our internes, who saw them when they were admitted
yesterday, an hour or two after the accident, will tell you that the
effusion did not then exist, and it is very probable that you will find
that No. ll's effusion, which is very small to-day, will increase con-
siderably to morrow and the following days, with more pain on
pressure.

It is too evident that the articular lesion which has so pood followed
these fractures of the femur has not been caused by the prolonged
immobility which Tessier, of Lyons, has indicated too absolutely a&
the cause of consecutive arthritis. It is the consequence of an early,
arthritis which might have been due to a concomitant contusion of!
the knee, but which, in these cases, seema to me to have been caused
by the extension to the syjiovial membrane of some of the leaioi
belonging to the injury of the bone. In an autopsy of a recent fractui
which I made in December, 18(58, I foand an infiltration of blood
'hich, starting from the interfragmentary space, extended almost
ito the sub-synovial tissue of the knee, although the fracture was in
^e middle third. During our late war we had occasion to notice this,
same sub-synovial infiltration of blood, which M. Berger, Demonstrator
of Anatomy, has further studied and confirmed by experiments upon
animals, in a work not yet published.

I cannot say whether this dropsical arthritis, occurring upon these
three patients soon after the accident, and which I have found during
the last twelve years upon nearly all the patients whom I have treated
for fraeture of the thigh, is always the consequence of an infiltration
of blood into the sub-synovial connective tissue, or whether it is not
due in certain cases exclusively or principally to the propagation
towards tlie articulation of the viident phlegmasia starting from the
seat of the fracture. I only call your attention to this early arthritis,
because, without being dangerous, without interfering with consolida-
tion, it explains the principal origin of the articular rigidities which
are one of the principal causes of the trouble in the movements after
-fractures of the thigh.

1 looked to see if pressure was painful and ifthere was an appreciable
ilitig over the articulation of the hip. I ^uod nothing there, and

158 FRACTURES OF THE LIMB3.

cannot say that there ia a coso-fernoral as well as a femoro-tibiai
arthritis.

Moreover, it is to be noticed that the articulation placed above the
fracture, in this bone as in other.-*, is more rarely afi'ected with con-
secutive inflammation than is the articulation below. T do not say
that it is never affected, for I have found in several patients after
fracture of the thigh a prolonged stiffness of the hip which indicated
the consequences of an arthritis. I only say that this complication
is hot common, while arthritis of the knee is almost constant.

We noticcil at first sight that the thigh was gathered up on itself
like a leech, and that it seemed to swell out forwards. Let us try to
interpret this disposition and to determine what ought to be the
reciprocal position of the fragments. It is clearly understood that
the fragments have undergone a rotary displacement, for the leg and
the knee lie upon their outer side, and an angular displacement for
the centre of the thigh is very prominent. Moreover, since the limb
ia shortened, there is a third kind of displacement, that is, an overlap-
ping or longitudinal displacement together with a transverse displace-
ment. Shortening exists always in the adult, and can be explained,
as our predecessors understood, by the obliquity of the fracture; but
it is also found in cases where the fracture, instead of being purely
oblique, is toothed, with or without fissure, described by Gerdy as
spiral fracture. Tt ia produced when the fragments, whatever may
be the direction of the fracture, no longer meet one another directly,
and it is due to the action of all the muscles of the thigh which draw
the lower fragment upwards and inwards, and sometimes backwards,
causing it to overlap the upper one more or less, and in any case, to
an extent which will increase during the following days, as it will be
easy for you to see in these patients. At the same time the upper
fragment is drawn upwards and outwards by the psoas. We found
the shortening in Nos. 5 and 11 to be an inch and a quarter, and in
No. 46 it was about two inches and a quarter. This difference is due
to the latter fracture being trochanteric, that is to say, situated much
higher than in the two other cases, and to the upper fragment being
drawn much more forcibly forwards and outwards by the psoaa, while
the lower one is drawn upwards, inwards, and backwards. In this
case then there is not only overlapping, but also great angular dis-
placement which increases the shortening.

Iheprognosis in these cases is not bad, in the sense that they will
recover, but they will prohably not recover wiihovl shortening. You
still aee in our wards a fourth patient who has been there for seventy-
five days. He ia beginning to walk, but his right thigh is two inches
shorter than the left. Well, there is reason to fear that, notwithstand-
ing all our care, those of whom I am speaking to-day will retain a
shortening, and it is even probable that this shortening will be a
little greater at the end of the treatment than it was after the limb
had been set. That unfortunately is the rule in fractures of the
thigh in the adult.

It is true that it will be corrected in part by the instinctive lower-
ing of the pelvis, and ia part by wearing a heel a little higher upoe

in I

SIMPLE FBACTURES OF THE SHAFT OF THE FBMCK. 159 |

the injured side, and that ultimately the deformity will scarcely ba
perceived.

Does that mean, in a word, lliut these patients will be lame?

Here, gentlemen, we must iliatinguiah between tbe primitive or
temporary, and the definitive results.

As for the first, there is no doubt; after the seventy-6ve or eighty
days of confinement to the bed which are generally necessary for th«
consolidation of fractures of the shaft of the femur in adults, we shall
allow the patients to walk. But they will only be able to do so with
the aid of crutches, which they will continue to use for two, three, of,
four months. Three principal causes will prevent their doing othepJ
wise; these are: —

Isl. The di&erenuein the length of the limbs, of which we have j
spoken.

2d. The feebleness of the muscles resulting from the prolonged
inaction, and from the slight atrophy which broken limbs always
undengo, as I often have occasion to tell you (see page 71). ,

3d. The persistence, in the chronic condition, of the dropaical]
synovitis of which I spoke a moment ago, For if this synovitis
resembles the others of this kind which I have seen, it will not be of
short duration, as it is in children. It will continue during the whole
of treatment, and for a so much longer time thereafter as the

.lients are older. Thus I expect it to last much longer in No. 11,

lo is 56 years old, than in the two others, one of whom is 35, the
41 years old,

After having walked upon crutches for a time, which will vary,
according to the subjects, from two to six months, our patients will
begin to use a cane, and will certainly limp very distinctly for several
inontlis. I estimate at about a year the time tliat is necessary for the
walk to become what it can be and will be during the rest of the 1:"
It is at the end of that time that we .shall be able to determine what
I called a moment ago the definitive results. I expect them to vary
'n these three cases.

No. 5, who is '65 years old, and whose fracture is in the middle of
femur, will undoubtedly limp very little, perhaps not at all,

itwithslauding the shortening of from one to one and a half inches,

hich I presume he will retain, and this absence of limping will be

due to this, that his muscles, although remaining slightly atrophied,

will have recovered enough energy of contraction to correct the

disadvautage resulting from the shortness of the lever. It will also

due to the fact that this shortness will not be excessive, and that

knee will have recovered all its movements, the synovial meni-

ne nut having retained any consecutive rigidity.

In No, 11 I expect the lameness to he more distinct, not on account

the shortening, which I presume will beabout the same as in No. 6,

It because he is older. For I fear that the muscles, after their pro-

iDged inactivity and in spite of the integrity of their innervation,

will not recover their former contractile energy ; and I am also leaa

certain about the consequences of the arthritis; for experience has

logbt nio that aabacute, spontaneous arthritis, pacing to the chronio

160 FRACTURES OF THE LIMBS.

condition, as arthritis following fraeturea almost always does, is
followed by a synovial rigiility of which we see frequent exanijiles
in frncturesof the lower extremity of the radius. Now these riglditie:^,
as I have often told you and shall tell you often again, are more
marked and permanent as the subjects are older

Finally, in No. 46, the one who has the siib-trochanteric fractnre,
I expect, as a definitive result, a very marked lameness, partly on
account of muscular weakness, partly on account of a certain degree
of synovial rigidity which may remain, bat chiefly on account of the
shortening which is now two and a half inches, and may ultimately
be three or three and a half, since, during the whole inflammatory
period, that is to say, so long as the fragments are not united by a
substance possessed of a certain solidity, the muacuJnr tonicity will
continue to act and will constantly increase the shortness.

My fear will not be justiSed in this patient if I can obtain by
continuous extension a notable diminution of the shortening.

But I argue on the supposition, which may become a reality, that
the apparatus for making extension will not be supported, or, if sup-
ported, will be insufficient.

Treatment.— Jn these three patients we have to meet the same indi-
cations as in all other fractures: make and maintain reduction.

To make the reduction, you saw to what manoauvre I had recourse:
an assistant, placed on the injured side, pressed firmly with both hands
upon the patient's iliac spines no as to fix the pelvis firmly. Another
one, placed at the foot of the bed, grasped the foot as in fractures of
the leg. He first straightened the foot which was rotated outwards,
then by drawing it towards himself he made what is called extension,
while the first assistant made counter-extension. Meanwhile I, stand-
ing beside the limb, tried with both hands to correct the deformity,
pressing the upper fragment inwards and the lower fragment outward.s.
These two manceuvres caused great pain, and you saw what results
I obtained.

The rotary displacement (rotation of the foot outwards) was per-
fectly corrected in all three patients. The angular displacement was
also corrected in Noa. 5 and 11, but only imperfectly so in No. 46,
who has the sub- trochanteric fracture, and in whom, as you know,
the angular displacement is much greater on account of the powerful
action of the psoas, which is inserted into the upper fragment and
draws it forwards and outwards, and whose contraction it was impos-
sible for us to overcome entirely.

But in no one of the patients were we able to correct the longitudi-
nal and transverse displacements, displacements closely allied with
one another, or of which the second, at least, is essentially dependent
upon the first. For you understand perfectly that the contact of the
lateral faces of the two fragments can only end when the femur has
recovered its length.

I mention the imposaibility of correcting the shortening by the
manceuvre of simple reduction, because many of your classical authors
do not lay sufficient stress upon this impossibility. Some of them
^eak of reduction as a thing which always succeeds if properly

SIMPLE FRACTURES OF THE SHAFT OF THE FEUUB

16ll

made; others intimate that in a eertaia number of cases the onl_"^J
indication is to correct the angular and rotary displacements, and!
ibat nothing is to be done about overriding because it does not exist, f
This is perhaps true for some children, but it is not exact for adults, '
In them fracture of the shaft of the femur is always accompanied byJ
overriding or, what amounts to the same thing, shortening or longi-J
tiidinal displacement, and if in some cases it has not been recognizt '
it is because the surgeon has not measured the limb and has be
deceived by the inclination of the pelvis which makes both legs set
of the same length. Not only is there shortening in fractures of thai
shaft of the femur in adults, but it cannot be corrected by ordinaryj
simple reduction, such as is made with the hands, according to th^
indications of the authors, and during the first days which follow th»
accident.

Can it be afterwards corrected by other means ? We shall examiner^
that question in a moment.

But I wished first to formulate, from what has occurred in (
three patients and from what I have seen in many others, these prop-B
ositions; Ist, that the immediate correction of the shortening by the^
hands alone, and without the aid of anesthesia, is impossible in moat
cases, and it is through prudence that I do not say in all cases, of
fracture of the thigh in adults; 2d, that if this correction can be
obtained early, it is by anesthesia. It may be obtained tardily and
slowly by the prolonged use of continuous extension combined with
that of retention, but unfortunately this method encounters difficulties
of execution which make us fear we shall not reach the desired end,

I now resume the history of our three patients, and I say that in J
alt three T made the ordinary reduction without obtaining a satisfao- ,
tory result so far as the shortening was concerned. But there is ona 1
of thein, No. 5, the youngest of the three, and the one who seemed to.l
me to be ibe least affected with alcoholism, upon whom you saw me I
use chloroform the next day and renew the attempt at reduction.
Scultet apparatus, arranged like the one for the leg, but extending I
from the groin to the foot, had been previously placed below the |
broken limb, and while an assistant held the foot firmly and was j
ready to make extension, and another pressed upon the pelvis for I
counter extension, the patient was brought under the influence of"]
chloroform with the ordinary precautions, and especially the ordinary
intermittecces. We had some difficulty to obtain resolution, and it !
was preceded by a period of great agitation, during which the patient
moved the broken limb as freely as the other one, caused the upper
fragment to project under the skin, and increased by the violent
contraction of his muscles all the displacements with which you are
acquainted. Standing on the outer side I had to hold the fracture
very firmly with both hands to oppose this powerful muscular action,
and you saw, nevertheless, that at certain moments my opposition
was overcome, and I was obliged to ask another assistant to help me
hold the fragments. Finally quiet was obtained, the muscles became i
soft, and I made the reduction. I measured the limb rather rapidly,
11

162 • FRACTCRKS OF THE LiMBS.

and it seemed to me that there remained barely aa eighth oF an inch
of shortening; I then applied the Scultet apparatus.

In the other two cases I did not have recourse to anjesthesia to
make the reduction, and for these reason : one of them, No, 11, ia a
teamster more than 5fi years old, and greatly given to drink; now
' you know that in such patients niusenlar resolution is difficult and
slow to obtain. It is necessary to give a great deal of chloroform
and consequently expose the subjects to the dangers of this agent,
dangers which exist especially during the days which follow great
traumatic lesions. It Is also necessary to pass through a much longer
and more intense period of excitation, during which perforation of
the skin by the fragments is not impossible. This accident bappenetl
to one of my patients in the HSpital Cochin in 1858. Two of us held
the fragments as firmly as possible, but the patient struggled so
violently several times that the limb slipped through our hands and
a point of the upper fragment pierced the skin. This perforation
healed by first intention, thanks to the occlu.sive dressing immediately
applied. But it is none the leas true that this possible complication
and even the danger of increasing the tearing of the muscles and
periosteum during these struggles, necessitates a certain reserve in
the use of anaesthesia in cases of this kind, and are even u contra-
indication in patients who are rather old and alcoholic.

The other patient, the one with the aub-trochanteric fracture (No.
46), has so much shortening that I could not hope to obtain a perma-
nent diminution of it by means of anesthesia. The little that I might
have obtained would certainly not have lasted, and therefore it was
useless to expose the patient to the risks of chloroform.

Let us now examine the second question, that of reduction. How
shall these fractures be confined and immobilized, and what pre-
cautions shall we have to take during this retention?

For two of the patients, Kos. 5 and 11, the problem is already in
great part solved. I have applied the Scultet apparatus, to one of
them after having made reduction during aniesthelic sleep, to the
other without this preliminary precaution. I took care — after having
wrapped the leg in the compresses and bands which form the inside
of this apparatus, and after having applied a very long external
cushion of chaft' which reached from above the crest of the iiiom lo
below the edge of the foot, after having also applied internal and
anterior cushions, then the three splints corresponding to these
cushions, and after having closed the femoral and tibial portions of
the apparatus with the buckled straps — I took care, I say to complete
the dressing with a body bandage applied about the pelvis and sewed
fast to the outer envelope of the Sunltet apparatus, and then placed
the patients on the mechanical bed.' I shall not use the water-bed
unless sores appear on the sacrum and make me fear an eschar.

1 have also told the patients not to sit up in hied, to eat while lying
down, and to move as tittle as possible. I shall prescribe in a few
days one or two drachms of the phosphate of lime daily.

I shall renew the apparatus every third or fourth day during the

m SIMPLE FRACITURES OP THE SHAFT OP THE FEHUB, IKSj

Srst Fortnight, and each time thnt I l]o so I shall make fresh attempts I
to overcame the shortening. I <io not hope to diminish it very mucti'l
by these repeateci reductions, but I shall at least be able to oppose J
the increase which tends to take place during the first two or three j
weeks. I

After the twentieth day I shall renew the apparatus only every' J
eighth or tenth day; I shall only have to tighten the outer Btraps^l
when I find thera relaxed. 1

On the sixtieth day I shall see if any mobility remains, by making'^
with precaution the inanceuvres which you saw me employ the first
day to detect this sign. If I no longer find mobility I shall leave the
limb uncovered an(i tell the patient to make a few movements of his
toes, foot, and knee. I shall myself communicate some from lime to ,
time to combat rigidity of the articulations, especially of the knee, i
If I still find mobility, I shall reapply the apparatus and leave it,.i
renewing it from time to time, until consolidation is obtained. I

At what period will I allow the patients to get out of bed and walk^l
with crutches? I shall wait at least until the eightieth day, and'T
probably until the ninetieth. For one of the things which I fear, f
■ind which should be most feared after fracture of the thigh, is th&'l
breaking of the callus by ft fall, even a very simple one, while wi "
ing or standing. I have seen these iterative fractures on the seven-'
lieth and aevenly-fifthdays, in patients who had left their bed too soon,',
in opposition to my advice, and then it required three months more ta I
get consolidation. ' f

In general, I let the patients get up only after I have demonstrated I
by several trials the absence of abnormal mobility and the patient'g I
ability to raise the heel five or six inches from the bed without bend-
ing the knee.

You wili perhaps ask why I have given the preference to the Scul-
tet bandage, with the limb extended; why I did not choose, as has
been recommended, and as you have seen me do, the same apparatus
with the limb bent upon aduuble inclined plane; why I do not speak ,
of an immovable bandage, and why I do not use continuous extension I
for all three of our patients, as I am going to do for the last one of'i
them.

These are my answers : —

1st. As for the Scuitet apparatus with the limb in semi-flexion, I
recognize in it one advantage, which is that this position of the knee
seems to cause a less rebellious arthritis and leas consecutive rigidity, t

Nevertheless the fact is not yet established by sufficiently numerous i
observations, to serse as a basis of treatment; and, on the other side, "
I have often seen this po.sition of senii-fiexion cause intolerable pain
in the calf of the leg, so that the inclined plane had to be removed
and the limb placed in extension. Indeed, in two of my patients,
tiiis compression of the calf of the leg was followed by obliteration of '
the popliteal vein and painful oedema of the leg.

I know that this obnoxious compression can be avoided by using,

instead of the wooden inclined plane, one made with bags of chaff, as

Dupuytreu and Sanson did. But I sliw that these bags yielded readily,

^^ind (hat to replace them and re-establish the aemi-flexwa t^\e. Uwv*^

18i FBACTUBBS OF THE LIUB3.

had to be moved three or four times every day, which ia a disadvan-
tage. And as finally oonsecutive rigidity ia not completely prevented
by semi-flexion, and as that which follows extension disappears, I do
lot see any real utility in adopting semi-flesion as an absolute role,

2d. I do not intend to employ an immovable apparatus, beeanse it
would no more prevent shortening than will the one which we have
chosen, and because it would perhaps permit the reproduction of
angular displacement. For sixty to eighty days of immobility ara
necessary. If the limb was enveloped in a pluater, silicated, or dex-
trinated bandage, the application would be made by the fifteenth or
twentieth day; for, if applied later, it would be of no use It would
have to remain in place for from forty to fifty days. Now during
this time the limb would diminish in size, a gap would result, and
the fragments, being less well supported, might undergo longitudinal
displacement, I much prefer the movable bandage, which I tighleti
wheu relaxed, and which T renew entirely from time to time. I thus
support the fracture mUch better, and avoid more surely very vicious
consolidations.

3d. Why not an apparatus to make continuous extension? Theo-
retically, this mode of treatment is reduction, for if we cannot, with
our hands and in a single attempt, overcome the resistance of the
muscles which produce the shortening, it is logical to hope that this
resistance can be conquered by a long-continued mechanical traction.
That is the thought which guided Brunuinghnusen, Desault, Boyer,
Baumers, F. Martin, and all the surgeons who, before and since their
time, have invented apparatuses for continuous extension for the
treatment of fractures of the femur.

Notice this well, gentlemen :—

The idea of continuous extension is very rational; many appara-
tuses inspired by this idea have been invented. None of them thus
far have been able to take definitive rank in practice. From lime to
time a new one is invented because the inconveniences and insuffi-
ciency of the others are recognized.

Whence comes this difficulty of making the practice accord with
the theory ? It comes from this, that to overcome the very energetic
muscular resistance against which they have to contend, these appa-
ratuses for continuous extension have, on the one hand, to perma-
nently exert strong tractions which are in themselves painful, and, on
the other hand, to apply the extension and counter- ex tension at certain
parts of the limb where the pressure causes pain, and sometimes
eschars. That which has prevented, then, the use of these appara-
tuses from becoming general is found first in these two results: pain
aud eschars.

There is also a third rtason ■. in many eases, after having subjected
the patients to these inconveniences, the shortening has persisted.
Those who have not given close attention, and who have not measured,
may have been deceived by a lowering of the pelvis which hid the
real shortness ; but those who measured have almost always found a
shortening of from one to one and a half inchea, and have been obliged
to recognize that by these sufferings, supported for several weeks,
they have barely gained from one-quarter to three-quarters of an io^^M

SIMPLE FBACTDRK8 OF THE SHAFT OF THE FBM

[There ia also a fourth reasoD. "When the patients are young, the
ortening, if nut more than one and a half inches, does not make'
mom limp permanently. Why then expose them to the paina of con-
tinuous extenaion? When they are old the shortening will certainly
make them limp, but they will also be much leas able to bear extension;
they will have eschars more easily, and, in consequence, .incur greater
danger. Is it not better, then, to bo satistied with simple retention,
which will leave a little more shortening, but will give more tranquil-
lity to the patient and surgeon ?

Such are the reasons, gentlemen, which have prevented, and will
long prevent, the use of apparatuses for continuous extension from.
becoming general in praciiee.

Fig. 17.

165 ^1

the ^M
make' ^H

Kig. IB.

But these reasons are not sufficient to cause us to reject them abso-
lutely. I understand why they should try continuous extension f
cases where the shortening ia very great;
but it should be done only on the condi-
tion of watching the apparatus atten-
tively, so as to avoid eschars and to
diminish as much as possible the pain
caused by the tractions. These are the
ideas which have guided me in the treat-
ment of our last patient. I might have
used Baumer's method, in which counter-
extension is made upon the pelvis at the
genito-crural Fnld, or that which is known
■ds the American splint, in which the ax-
illa on the side corresponding to the
fracture is used for this purpose; bUt I
preferred the apparatus now more gene-
rally used in the Paris hospitals (Fig.
i7), which was invented by Dr. Henne-
Co

I'BitausiaD

166

FEACTURKS OF TH

I shall not give you a minute descriptiou: it is sufScient to show it
to yon, and to recall in a. few words its principal points and advan-
tages. It consists of a trough in which the thigh rests, jiHowing the
knee to be flexed, the leg being outside the bed and the foot upon n
chair.

Counter-extension is made by means of pressure exerted — ^Ist, upon
the iachium by a curved pad (I, Fig. 17), attached to the upper part
of the trough; 2d, upon the outer iliac fossa by anotlier pad, G; bil,
upon the horizontal ramus of the pubis by another pad, H. The two
latter are attached to the rest of the apparatus by two rods sliding
through a hinged clasp, E. Counter-extensioD is made by means of
the bracelet represented in Figure 18, which surrounds the thigh, and
from which extend two elastic bands, cd, c' d', a sort of artificial mus-
cle, which are attached to buttons on the two long lateral parts of the
main apparatus.

I shall apply this apparatus about the twelfth or fifteenth day, after
the inflammatory period is ended. If things go on aa in three other
patients upon whom I have had occasion to employ this mode of
treatment, you will see that I shall have to change the situation of the
pads several times, so as to render them endurable; that the patient
will be tormented by the pains caused by extension; that it will be
necessary, from to time, to diminish the traction exerted by the elas-
tic bands; and finally, that the foot and lower part of the leg will
become cedematoua, notwithstanding the roller bandage which will
previously have been placed about them. If the" patient is not too
sensitive, and if he bears the pain bravely, we shall perhaps succeed
in curing him without shortening, or with a shortening of about an
inch. But if the pain is intolerable, and if, to diminish it, we are
obliged too often to loosen the elastic bands, the result will be leas
fortunate, and there will remain a shortening of two inches or more.
Everything here depends upon the degree of sensibility and energy of
the patient; and it is precisely because we find only few who arc able
to bear the pain caused by this and by every other apparatus for
continuous extension, that it cannot be adopted in all cases. Above
all, do not try it upon children, women, or old people ; for to the pain
you might easily add eschars, which would increase the suffering am}

ghtt

angerous.

FEACTURS3 OF THE NECK OF THE FKMUK.

LECTURE XXI.

FRACTURES OP THE NECK OF THE FEMUR.

rractiima of tlie ueck of the Tumur in old women— DiffiuaUy of detenniniDg upon
what paint the full ocourrod — Fuiictioiial and phrBical SfiDjitomB — IiupoBSl-
billtj and ustilessneBa of the diagnoaia !>et>reeQ iutrS' and extm-cnpanlar frao-
tnres — Aatley Cooper's error as to the iuflueuee of age — Ohacurity of tha autliora
upon the differential signs — Be satisfied wild presatxiptioiia upon the seat of the
frftoluro aa upon the penetration— Simple treltmeut in all oaaaa — Indioation ti»>'
avoid pain — Rujectiou of apparatosea for liontinuona exleuaion.

OrBNTLEMEN: We have at Uiia moment in ward Ste. Catherine two
bid women, one of whom was brought to ug the day before yesterday,
hbe other a week ago. Both of them fell while walking, without great
violence.

The first (No. fi), 69 years old, slipped in her room, and, after
several eft'orta to keep her balance, fell upon the right side.

The second (No. 20), 71 years old, made a misstep in the street and
fell upon her left side.

1 asked them particularly what part of their body received the force
of the fall ; they answered that it was the side, and indicated with the
hand, the one more especially the hip, the other the hip and buttocks.
But both showed a certain hesitation in it, and said they did not know
very well, but that they thought they fell in such or suuh a way.

However that may be, neither was able to get up and walk, and
'ley were brought here upon stretchers.

(■On examining thera we find in both the following symptoms: —
• lat. Functional Symptoma. — Both suffer when they try to move in
ted. If the hips are raised for the purpose of passing a bed-pan, they
Jtry out; when not moved they suffer little. The one who has been
ptere for a week suffered during the first two nights, but scarcely at
I now. The one who was admitted the day before yesterday suffere
i-great deal, and had a bad night on account of the pain.
I I told them to raise the foot from the bed ; neither one was able to
^o so. No. ti took her thigh in both hands and raised it, but at the
Bme lime she bent her knee, and her foot slid along the bed without
icifig raised above it. No. 20, who aufiera more, was able to make.
Sio movement.

Both of them have an imperfectly circumscribed swelling of the
upper part of the thigh; the one who was admitted most recently has
an extensive ecchymosis in the trochanteric region.

2d, Physical Symptoms. — I called your attention first to the attitude

kr the patients. They were lying upon the back, and a little on the

ttinful aide, and begged earnestly not to have the position changed,

%s injured limb was rotated outwards, so that the outer edge of tho

FRACTCJRK3 OF THE LIMB3.

foot rested upon the bed, anil tbe heel corresponded to the spnce
between the internal malleolus and the heel of the other Foot.

The better to appreciate this attitude, I persuaded the two patients
to allow themselvea to be placed fiat upon their backs, and then I
showed you that the rotation of the limb outwards peraiHted, and that
there was also a notable lowering of the pelvis, For, stretching a
string from one spine of the ilium to the other, I showed you that its
direction was oblique with reference to the median line of the body,
the end oii the injured aide being half an inch lower than a line cross-
ing at right angles from the other spine.

Finally, there is in both a shortening which can be seen and meas-
ured; it can be seen, because the heel of the injured side is clearly
higher than the other; and by measuring the distance between the
spine of the ilium and the malleoli on each side, I find a difference of
about three-quarters of an inch in No. 6, and one inch in No. 20, laay
about; for whatever care you may take, it is difficult to place the
measure bo accurately upon tlie difiarent points as to be sure that yon
do not make a mistake of a line or two. But the important fact is to
determine the existence of shortening; now, it certainly exists here,
and the measurement shows it to be a little greater than it seems.
You onderstand why ; the pelvis is inclined, as it is in almost ail painful
diseases of the hip and of the upper part of the thigh, and this incli-
nation hides part of the shortening.

I did not look for either mobility or crepitation; for, gentlemen,
with the signs which I have just pointed out, doubt is not possible.
These two women have fracture of the neck of the femur.

A simple contusion might indeed cause the trouble in the move-
ments and the pain which we And here, but it would not cause rotation
outwards and shortening. We could be mistaken only if the contu-
sion happened to a patient who, for a long time previously, had had
dry arthritis or morbus coxa senilis, which had caused rotation outwards
and shortening. It was to guard against this error that you heard
me ask if they had limped or suftered in the hip for several years,
and it was because they answered negatively that I do not have to
believe this is a fresh contusion superadded to an old dry arthritis.

Nor have yon reason to think of a traumatic dislocation. For, in
addition to the fact that dislocation is rare in old people, and that it is
produceu by a fall from a high place rather than by causes so slight
as those which have intervened here, we do not find the symptoms of
the most frequent, the iliac, dislocation, since in it the rotation is
inwards, not outwards, Supra-pubic dislocation is the only one which
is accompanied by rotation outwards and shortening, and it is easily
recognized by the prominence formed by the head of the femur as it
lies upon the pubes.

We have decided now the most important point of the diagnosis.
These patients have fracture of the neck of the femur.

But there is another point which, if I turn to the descriptions of
our best authors, ought also to have a certain clinical importance. Is
the fracture extra capsular, intracapsular, or mixed, that is, both intra-
and extra-capsular?

Ifracti;be3 of the neck of the femur. 169^^1

Tf you read the works of Astley Cooper and Malgaigne you will ^^M
nd different chapters for extra- and intra-capsiilar ; it yon read those ^^M

Bad different chapters for extra- and intra-capsiilar ; it yon read those
of Vidal de Cassis and Ndlalon you will not find, it is true, a separate
description of the two varieties, but they insist so strongly upon the
difterences and the diagnosis that one ought to conclude iu the utility
and possibility of a differential diagnosis,

I see, with pleasure, that M. S. Duplay' has not followed the same
■ road, and passes over in silence the diagnosis of intra- and extra-
capsular fractures. I like to think that this is due to my clinical
lessons at La Piti^, in which he heard me develop the idea that a
rigorous diagnosis between extra- and intra-capsular fractures is both
ioipossible and useless. Impossible, beoause the differential signs
given by the authors are inexact or cannot be detected upon the
living subject. Would you like the proof? Examine any one of the
differential points given by A, Cooper and Malgaigne.

Astley Cooper insisted upon one means of diagnosis, which, if it
was true, would be very convenient. He said: Almost all fractures'
of the neck of the femur, after 50 years, are intra. capsular, and
before 60 years, extracapsular; and he adds in proof of this asser-
tion, that of 225 persons over 50 years of age, in whom he found
fracture of the neck of the femur, in only two was it estra-cspaular;
in the 223 others the fracture was intra-eapsular. Our two patients,
being more than 60 years old, should therefore have intra-capsular
fracture.

Astley Cooper here fell into a great mistake, from which he drew,
fortunately, an excellent iherapeutical conclusion. I explain this error
by these two circumstances, that he scarcely found in his autopsies
anything except intra-capsular fractures, and that he found them in
old people. For, in his time, they did not very well understand frac-
tures with penetration, tbey did not know that in order to detect them
upon the cadaver it is necessary to split the neck of the femur verti-
cally ; those who examined the pieces without taking this precaution,
failed to recognize e.xtra-capsular fractures. Astley Cooper theu
reasoned thus: When I make autopsies of fracture in old people, I
find only intra-capsular fractures; that is undoubtedly because they
are peculiar lo old people ; and without occupying himself with other
differential signs upon the living subject, he thought that age was
sufEicient to establish the diagnosis.

But facts soon appeared lo show that Astley Cooper was mistaken.
Bonnet (de Lyon), Rodet, and others after them, found in well-con-
ducted autopsies with vertical section of the neck, extracapsular
fractures with or without penetration, so that today it would be
difficult to say whether, after 50 years, the intra- or the extra-caps ular
fractures are most frequent.

A word, now, upon some of the differential signs given by Malgaigne
in the table placed at the end of his paragraph upon fractures of the
Wck of the femur.

• VuUia & Ouplay, Trnitfi d« FatliolngiB HxturiiH, touiH ii.

170 FBAOTURKa OF THE LIMBB.

1st. The intra capsular, he says, is caused by a fall upon the foot,
or the knee, or the buttocks; tbe extra-capsular, by a direct blow
upon the great trochanter. But you will not find out from my poor
old women, and you will never find out from other old people who
have broken the neck of the femur, whether they have fallen upon
the great trochanter, or upon the buttocks. Theae two regions are
too near each other for the patient to be able to say whether it was
upon the one or tbe other that be fell; and suppose that he fell upon
hia feet or knees — as, after such a fall, there is almost always another
backwards and sideways — how are you to know whether the fracture
was made before or after the fall upon the side?

I should also like to know how often the diagnosis has been verified
upon the cadaver. I doubt if it has ever been done. Maljiaigne, in
writing these lines, was evidently inspired by a work of M. Itodet,'
who had published this opinion after experiments made upon plaster
femurs. A piece of plaster in the shape of a femur dues uot at all
resemble a cancellous bone whose compact tissue has been thinned,
and whose cells have been enlarged by senile rarefaction ; for it is due
to variations of resistance in different points of its length resulting
from these anterior lesions, that the femur, after a blow, yields in one
point rather than in another.

2d. In tbe intracapsular, adds Malgaigna, there is little swelling,
no ecchymosis; in the extra- capsular, much ecchyniosis. T complain
here that the author did not contrast tbe swelling in the one with the
swelling in the other. Undoubtedly he was embarrassed by the diffi-
culty of being precise. As to the ecchymosis, the word much is very
elastic. Has our second patient much or little ? I could not say, and
in any case, it is not impossible that intra-capsular fracture should be
accompanied either by great contusion of the soft parts, or by a tearing
of the bone which might cause considerable ecchymosis.

You see then that the ecchymosis cannot supply a serious element
of the diagnosis.

3d, In the intra-capsular, continues Malgaigne, there is pain near
the in.sertion of the psoas; in tbe extra- capsular, the pain on pressure
is over the great trochanter.

Gentlemen, it is not possible to make pain on pressure a means of
diagnosis, for two reasons: first, because if the pressure is slighter
moderate it causes no pain, even where there is a fracture not far from
it, and because if it is great, it may cause pain itself, and not by trans-
mission of a shock to a neighbouring fracture; secondly, because,
supposing the pain on pressure to be due to a fracture, it may be
caused by fracture at the base as well as in the middle of the neck.

4th, In the intra-capsular, still according to Malgaigne, the short-
ening is limited to one and a quarter inches at the moat; in the extra-
capsular, the shortening is from one-quarter of an inch to two and a
quarter inches. Well, we have here four-fifths of an inch, and an
inch; consequently we are withia limits which allow us to believe in
owe as well as in tbe other.

FRACTURES OF THE NECK OF THB FKMITB

171

I do not wish to carry this critical examination any further. Mal-
gaigne gives as four more differential signs, all of them as difRcult to' |
determine as the preceding ones, and from no one of which can the |
clioicist draw a rigorous conclusion, and do not think that by group-
ing them all you can reach a coneliision. For, in this group you have I
a certain numher which are as much in favour of one as of the other' ]
variety.

Furthermore, that which obliges me to retain and allow you toj
retain no illusion upon this point, ia that pathological anatomy has j
often shown fractures which were at the same time extra-capsular and [
intra-capsular; by what signs are they to be distinguished? No one
hao given them, and yet it ia not logical to give the means for recog-
nizing the intra- and exlra-capaular, and not give the means for recog-
nizing a mixture of the two.

The truth is that upon this part of the diagnosis we may reach
presumptions, but never a certainty. Thus, in our first patient, I may J
presume the fracture ia intra-capaular because there has been no ecchy-'l
mopis and the paio has been moderate. In the other, I may presume 1
that the fracture is extra-eapauiar, because there is an ecchymosis, the
swelling is considerable, and the pain more severe. But, the reasons
which I give in favour of these presumptions might be completely
contradicted by an autopsy, or the fracture might prove to be a mixed
one.

I said also that this rigorous diagnosis between nn extra- and an
intra-capsular fracture was useless for the prognosis and treatment,
and consequently useless from a practical point of view.

I say that it is useless for the prognosis, Here I find my.self in the
presence of two contestable opiTiions which were advanced by Aalley
Cooper, and upon which he established his distinction between extra-
and intra- capsular fractures. The first was that intra-capsular fractures
did not consolidate, or consolidated only by a very thin fibrous callus ;
the second was the conclusion, or rather the intimation (for Astley
Cooper did not express himself categorically upon this point), that the
patients were condemned to an inevitable infirmity by the fact of this
entire or partial failure to consolidate. You see the utility which
this question of diagnosis would then have for the prognosis.

This one of our patients, who seems to me to have an intra-capsular
fracture, would not get consolidation, would henceforth walk onlv
with the aid of crutches, or at least with a cane and with great diffi-
culty, would be, in a word, condemned to an infirmity, while the other
one, who seems rather to have an extra-capsular fracture, would, unless
I am mistaken in tlie diagnosis, have bony consolidation and walk
very well. And as for the treatment, you see at once the consequence;
if iiitra-capsuinr fracture docs not consolidate, it is usele.'is to treat the
patient by confinement to the bed intended to assure the immobility
which ia a necessary condition to the formation of a regular bony
callus.

Gentlemen, it is very true — and the facts invoked by Astley Cooper
and before him, it must be admitted, by other authors, especially by
J. L. Petit and Boyer, are demonstrative upon this point — it is very

172 FBACTUBKS OF THE

true, I repeat, that intra-capaular fractures aometimes remain without
oiisoHdation, or heal only by means of an intermediate fibrous aub-
atanee, for the following reaaona : lat. Because the upper fragment is
short and no longer receives a sufficient quantity of nutritive material,
since it is supplied exclusively by small vessels accompanying the
round ligament ; 2d. Because the materials of the callus are poured
into and lost in the articular cavity, as in the case in fractures of
the patella. It is equally true that extra-capsular fractures, especially
when accompanied by penetration, consolidate by means of a bony
callus.

But besides these facts, which are common, there are many excep-
tions which do not allow us to establish absolute rules for the prog-
nosis. Thus, certain intra-capaular fractures form a bony callus;
Astley Cooper himself distinctly says so. These are the ones in which
a considerable part of the periosteum has remained intact about the
fragments, and, on the one hand, supports the vessels which feed the
upper fragments, and, on the other hand, opposes the escape of the
reparative materials into the synovial cavity. These are also the ones
in which, notwithstanding the rupture of the periosteum, bony stalae-
tiles form at the edge of the fragments and unite them at some points,
although inter -fragmentary consolidation is lacking. Furthermore, the
interfragmentary fibrous callus, when it forms, is sometimes strong
enough to give the neck of the femur as much solidity as if it had been
bony. You see theu that if, after an intra-capsular fracture, the bony
or fibrous callus can be as solid as that of an extra-capsular fracture,
there is no reason, ao far as the prognosis is concerned, to maintain
that the diagnosis would be of any great value. It would be if, to the
knowledge of the precise seat of the fracture, we could add that of the
other anatomical and physiological conditions, that is, the amount of
periosteum that has been preserved, the aptitude for the formation of
stalaotiform prominences. Now, as to these points, no author has ever
claimed to be able to make a rigorous diagnosis.

Moreover, it must not be believed that all extra-capsular fractures
consolidate with a bony callus; in some of them also it remains
fibrous.

I have seen two positive examples of this, and regret that I did not
preserve the specimens. In both cases it was fracture with penetra-
tion, and the injury had been received six months before in one case,
and eight months in the other. Taking the head of the femur in one
hand and the shaft in the other, an abnormal mobility could be found,
and one might have supposed that a bony callus united the fragments.
Bui, to examine the mode of reunion, I made with a saw a vertical
section through the bone, a section without which it would be impos-
sible to exactly appreciate the condition of the parts. This section
having been made, I first noticed the penetration of the upper frag-
ment into the lower one, the complete disappearance of the bony
substance that had been crushed, the diminution of the length of the
neck in consequence of this loss of substance, and finally an irregular
fibrous line of demarcation between the upper and lower fragments.
This line was about one-fifth of an inch thick. Its tissue was quite

I FRAOTURBS OF THE NECK Oy THE FEMOB.

dense and adhered firmly to the two fragments, so that the femur thm
repaired was perfectly able to sustain the weight of the body. It '
none the less trne that the callus was Qbrous as in many intra-capeuh
fractui'es. I proved this by macerating the piece for several week
at tlie end of which the fragments separated.

You see then there is nothing absolute, as to the method of consoli-
datiim, in one or the other variety, and we are authorized to-day t(
say that the rigorous diagnosis between them ia not useful fur the
prognosis.

It might be, however, if the method of consolidation was the only;
means of explaining the ease or the difficulty of walking after frao-
turea of the neck of tlie feinur. For I could understand that one'
should say: the old man afl'ected with intra- capsular fracture will
probably never walk, because hia conaolidation will be insulBoient,
and vice versd for the extra- capsular. But our anatomo-pathologicat
studies have shown u.=i that the difficulty in walking after this fracture,
as after all those which are near articulations, depends greatly upoQ
the consecutive arthritis and the diminished power of the muscles.
All patients who have fracture of the neck of the femur have trau-
matic arthritis almost inevitably when the lesion ia wholly or in part
intra articular ; it ia also very common, if not constant, in extra-artic-
ular fractures. How ia it possible to prevent the articulation which
isao near the solution of continuity from taking part in theconaecutive
phlegmasia? The intensity and the cftects of this arthritis vary
according to the subjects, and the varieties depend much more upon
their idiosyncrasies than upon the seat of the fracture. At the begin-
ning, then, it may be presumed with certainty that the patient will
have an arthritis; it may also be presumed, on account of the age
(fracture of the neck of the femur being, as you know, an affection of
old people), that this arthritis will become an incurable dry arthritis,
or if it doea not pass to that state, it will leave for many months »■
painful rigidity of the synovial membrane. I will admit, if you wish,
that these results are more probable after intra-capsular than extra-
capsular fractures; I wish to establiah, only, that they are possible
after both, and that from this point of view aldo, a perfect diagnoaia
would not have the value which is claimed for it.

Under the supposition that our second patient has an extra-eapsular
fracture, I ask myself if this fracture is with or without persistent
penetration. For the works of Hervez de Chegoin* and Alph. Kobert'
demonstrated plainly that in fractures of the neck of the femur, and
especially in' those at the base, or the extracapsular ones, the upper
fragment might penetrate the great trochanter and split it, in which
case fracture of the neck ia complicated by fracture of the great tro-
chanter. They also showed that, without splitting the great trochanter,
the upper fragment might lodge within it, crush its cancellous tissue,
and remain implanted there (Fig. IW); an important fact, for it leads

' Hervei de Chegoin, Journal asn6ral de MSdaoliip, 1S20, tome liiii. p. 3.

* Alph. Robert, M^oioire siir le» FraL-tims dll Cnl du tViiiiir auunrnpagnfieii Ae p6n6-
tratiou daiia In Tlasa apoiigittiis dii TrDuliHuter (U«iDoir«H dx I'Auadeiuie de H^diiuiim,
1847, louiH xlii. p. 4Bd>.

I
i

' 174 FBACTDRKS OF TH

to this conclusion, that there are fractures of the neck of the femtir in
which attempts at reduction cannot succeed, or if they succeed are
followed by a prompt return of the displacement. It is the same here
aa in fractures with crushing of the lower extremity of the tibia and
of the lower extremity of the radius.
Pis- 19- From the moment when tlie pressure

exerted by one of the fragments has
hollowed out the other by crushing it,
ttie resultant gap ia necessarily filled
the muscular action which draws
3 fragments into contact. If they
ould succeed in re establishing ite
turul length and direction of the
1 mb t would be by removing the
fragments from one another and aub-
st tut ng for their contact an empty
space which cannot persist, and to-
wards which the pelvi-femoral muscles
would very soon draw the lower frag-
ment. Moreover, under such circum-
stances the interlocking of the frag-
ments is such that our efforts cannot
disengage them, and for consolidation
their connection ia rather * advanta-
geous than not.

From this point of view there would
be some use in recognizing before-
hand the existence of penetration ; for
the therapeutical corollary would be
to make no exaggerated attempt to
™noei"u«Tiii!lie'X'b"i™V»nfe""° remedy the shortening and the out-

ward rotation But here again we
reach only presumptions. When the pain and the eechymosis make
UB think that the fracture is extra-capsular, we may at the same time
suppose that it is with penetration, because it is especially in such
cases that penetration is met with.

The presumption becomes greater, if by making an assistant stand
at the end of the bed, grasp the limb, and try to lengthen it and rotate
it inwards, we see that the two principal displacements (rotation out-
wards and shortening) do not yield, and that the attempt causes pain.
For in fracture without penetration it would seem as if the assistant's
hand ought not to encounter the same resistance as in fracture with
penetration. I have again to regret that I cannot give you this mode
of exploration as one leading to a positive conclusion. For, if the limb
lengthens, and the outward rotation is overcome easily, that will be a
proof that penetration, or at least irremediable penetration, does not
exist. But inability to correct either of these displacements may be due
to two causes; either to penetration, or to muscular resistance. Now,
to which of these two causes should we attribute it? This is precisely
' the question which we have to ask in the case of our second patient.

FRACTOBKa OF THE NECK OP THE FEMUR. 175

B hnve not been able by a gentle effort to correct either of the two

placements. I presume, but I am not certain, that ihia ia Hue lo

HipeneLralion, The question will be cleared up in n. few diiys. If il ia

lionly a muscular spasm it will disappear with the pain, and then if

"there is no penetration we shall be able to correct at least the rotation

outwards, ami probably also part of the shortening; if, on the contrary,

there is penetration we shall remain unable to correct the diapl

ments.

To recapitulate: you see, gentlemen, that if the etiological, anatomi-
il, and phyaiologieal studies relative to fracture of the neck of the
■mar, which have been made since the beginning of this century,
..iftve enlightened us upon the mode of production, the varieties of
location, the symptoms, the difficulties, and the method of consolida-
tion, the clinic has not found the means of recognizing, especially at
first, all the anatomical dispositions revealed by these studies. The
(Jiagnosia upon the living subject is precise only aa to the existence,
f the fracture, ami is reduced, on the other points, to presumptions..,

prefer to admit tbia before you rather than to transmit to you errora'

useless opiuiotis.

Prognosis. — Those who taught clinically twenty years ago, would
undoubtedly have told you that the prognosis was bad for both women,
and that death was imminent in a certain measure.

At the beginning of my studies, during my interna t under Profeasora-^
Roux and IJlandin, I remember to have seen patients afl'ected with-
fractures of this kind die after a few weeks, and to have had the
opportunity to make the autopsy. But ihii has no longer been ao-
'uring the last fii'leen or twenty years; the patients survive, and wb.
arely have occasion to make the autopsical examination of recent;
'actures of the neck of the femur.

Since I have been practising aa hospital surgeon, that is, since 1847,
I remember only one case of death during the fortnight following the
accident. It was at the Hopital Cochin, a woman, 82 years old, whose
fracture was extra-capsular with penetration.

The three or four other antopsies which I have had occasion tO'
make, were upon subjects who had had iheir fractures for several
months, who no longer suffered at all from them, and who died from
BOme other affection.

To what ia this change due? I attribute it to one single cause,.
that at the beginning of this century the surgeons, guided by false
ideas upon the indications of treatment, subjected their old people to
the pains of continuous extension. Hence insomnia, fever, loss of
appetite, and an alteration of the respiratory passages which carried,
them ofy, They said the patients died of hypostatic pneumonia due
lo horizontal decubitus, and they did not see that this pneumonia was
the ultimate lesion of a febrile affection consecutive to a painful con-
dition which old people cannot support. These pneumonias have-
almost disappeared since we have ceaaed to make our patienta snfler.

Does that mean, however, that our patients are exposed to ao altera-
tion of their health dependent upon the fracture? Although I have
Jittle fear of a fatal termination, still 1 ought to tell yoa here that o£r

I
I

op
•I

176 FRACTURES OP THE LIMB3.

^H nil fractures, thnt of the neck of the femur is; the one which has seemed
^H to me to cause the most fever during the firat days. Yoa know that
^H after fracture we have a first period, called inflammatory, during
^B which the predominant symptom is pain. T showed you, however,
^B that, during this period, piitients affected with fracture of the leg, or
^^t of the shaft oF the femur, or of the arm or forearm, did not have any
^H marked quickening of the pulae or elevation of temperature, or that,
^H if this elevation look place, it was temporary. In old people who
^H have fractures of the neck of the femur, on the other hand, we often
^H see during three or four days the pulae rise to ninety, the axillary
^B temperature increase two detjreea, and in those who are more than 80
^F years old eschars iiinn rapidly on ihe sacrum. T asked myself at the
time when we saw these fractures terminate quite frequently by death,
if this lever was not the consequence of a septiciemia starting from the
crushed spongy tissue, and if it did not deserve the name of septi-
cemic bone fever, and if the death should not be attributed to a pecu-
liar congestion of tlie bronchi and of the brain in the course of, and
by the fact of, this septicemia. Since the raortaiity has sensibly
diminished I have given up these explanations, or at, least I have
recognized that, if it is permitted to invoke a septicaimia, we must
admit that it is often slight, and that if wo do not torment the old
people with the pains of apparatuses, it limits itself to a few days of

Of our two patients, the one who was injured a week ago is entirely
without fever; the one whose fracture was received forty-eight hours
ago has a pulse of ninety-two, a little headache, loss of appetite, aod
thirst. But as there is no oppression, no dryness of the tongue, no
delirium, no commencing eschar upon the sacrum, 1 liuve the right to
hope that the fever will be temporary and mild.

If I have no fear for the life of our patients, I am not so certain about
the restoration of the shape and functions of the limb.

As for the shape, I hope that the one in No. 6, the one in whom I
suspect intra- capsular fracture, will recover without retaining rotation
outwards, because in the few movements which I communicated, it
seemed to me that this rotation outwards mii^ht be corrected.

The other, on the contrary, the one in whom I suspect an extra-
capsular fracture with penetration, will undoubtedly retain the de-
formity resulting from the persistence, of the rutatioti outwards, that
is to say, that when standing or walking, she will have the foot turned
outwards. This deformity will cause no great inconvenience, it is
true, but it is none the less to be mentioned in the prognosis. We
shall, moreover, have to direct some of our treatment towards it, for
it is possible that we may ultimately correct it, since I'do not eon-
aider it absolutely irreducible, although I am by no jnaans sure of '
being able to make it disappear.

On the other hand, these two patients will preserve a shortening of

the limb, for two reasons; first, because I shall not try to oppose it;

secondly, because if I should try, I should not succeed, the muscles on

the one hand, and the interlocking of the fragments on the other,

I (especially in the second patient), being obstacles against which W6

■ FRACTURK3 OF THK NECK OP TH K FKUUR. 177

can contend advantageously only by meana of excessive tractions,
which the patients caiiiiot support, and to which it would be cruel to
subject them.

Aa for the functions, I am obliged to leave you in uncertainty,
because their re-establishment depends upon individual conditions
which I cannot produce, although all my efforts should be directed
towards this end.

After a few weeks of confinement to the bed theae women will
begin to gat up and walk with crutehea. How long will that last?
If affairs go on fortunately, if bony or strong fibrous consolidation is
obtained, if the consecutive arthritis is resolved, if no false anchylosis
remains after three or four months, and if the muscles are not too
much weakened, the crutches will Ije replaced by a cane, and the
patients will be able to walk quite easily, lim.ping but little.

I know three old people, one of them 69, the other two more than.
80 years old, who broke the neck of the femur at 68 and 70 years of
age, and who for many years have walked without limping — can even
walk several milea easily. It ia true that they are men, and vigor-
ous ones.

The old women whom I have known or still know in private prac-
tice, with fracture of the neck of the femur, have continued to Hmp,
to aufler, to walk with a crutch or a caoe, and for only short dis-
tances.

Nevertheless, I saw at the Hopital de la Piti^, in 1866, a woman
66 years old, whom I had treated for a fracture of the neck of the
left femur, by simple rest in bed for three weeks, and who, at the
end of this time, had walked with crutches. She left the hospital
seven weeks after her admission, using only a cane, not sufl'ering,
and able to walk without fatigue for about fifteen minutes. After
her departure she continued to walk belter and better, still with the
aid of a stick, but taking walks of about half an hour without too
much fatigue. The patient came to see u.'i several times, and I pre-
sented her aa an example of good coaaoliclatioa after a fracture whose
extra- or intra-capaular position I had not been able to determine
strictly, for the reasons which you know. Seven or eight months
later she was received into the service of my colleague and friend,
M. Empis, for a disease of which she died. We made the autopsy,
and, to my great aurpriae, I found an intracapsular fracture which
was consolidated neither by bony tissue nor by fibrous tissue. The
fragments, held together only by a few pieces of periosteum, slipped
upon one another, forming a pseudarthrosis like an arihrodia.

I (ear then, becauae this is a cjuite frequent termiuation in both
aexes, and still more frequent in women than in men, that our two
patients will never walk without crutches, will have pain caused by
movements, and, in a word, will remain infirm. But there is no
certainty upon this point. For iheao bad results may depend either
upon a non-conaolidatiun, or upon an incurable dry arthritis, or upon
muscular weakness, or upon all three causes united. Now, I cannot
say definitively whether these causes will intervene; for the patients
may not have dry arthritis. They may have a aulBcieal consolidation ;;

178 FKACTUHE3 OF THE LIMBS,

I liave just told you that even with a pseudarthrosis it was not impos-
sible to walk. Let us hope for a good result, let us try to obtain il,
but without counting absolutely apon it. Such, in short, ought to
be our prognoaic.

Trealment. — "What shall we do for these two patients?

Certainly it would seem rational to employ apparatuses which
correct external rotation and shortening, t". J. Desault' formulated
this indication perfeetly, and invented a splint for continuous exten-
sion which still bears his name. Guided by the idea of Desault,
Boyer invented another splint supplied with screw which answered
the purpose still better, and which had a certain vogue.

It ia a remarkable fact, but these apparatuses for continuous exten-
sion caused pain, fever, somctiinea eschars, always sleeplessness and
loss of appetite, and certainly the death of a good number of old
people. Those who survived preserved none the less rotation out-
wards, shortening, and more or less infirmity ; nevertheless they were
30 penetrated with the idea that the surgeon's duty was to oppose the
deformity, and that the death was the result of unfortunate conditions
in the patient, that they were finally led to abandon apparatuses for
continuous extension by false theories rather than by the results of
observation.

It is to two great surgeons, Aatley Cooper and Dupuytren, that we
are indebted i'or these theories, which, to the great profit of the
patients, led to the abandonment of these apparatuses.

You already know Astley Cooper's: fractures are intra-capsular in
old people, and intracapsular fractures do not consolidate. Conse-
quently, whenever the patients are more than 50 years old it is not
necessary to subject them to the pains of continuous extension. We
now know that in old people fractures are sometimes extra-capsulor,
and that intra-capsular fractures can consolidate, but we have retained
the deduction, because ob.^ervation has shown ns, since Astley Cooper's
fortunate modification of the treatment, that fractures of the neck of
the femur treated, without continuous extension heal just as well as,
and even better than, with it.

On his side, Dupuytren, in proposing and employing treatment by
means of semi-flexion, had the idea that in the semi-flexed position,
counter-extension was miide by the weight of the pelvis, iiiid exten-
sion by the weight of the limb, and he asserted that as this position
gave, without apparatus, continuous extension, it enabled us to obtain
a cure without shortening. In this there was an error of interpre-
tation and an error of observation. But the impulse given to the
practice by Dupuytren was none the less very salutary, in protecting
the unfortunate old people from the pain of continuous extension.

To-day, gentlemen, you may be very sure of two things : —

The first ia that in old people apparatuses to make continuous
extension cannot stretch sulTicientiy, and especially for a long enough
time to oppose successfully the two causes of shortening of which J
Bpoke amoment ago: muscular action and crushin

' DnAOlt, ConrB thfiorique et pratiqns da Cliuiqne BxiBrne ; FstiB, ui.

FKACTUREa OF TUB SECK OF THE FEMUR. 1791

Ik The second is that, even while not exceeding certain limits, it pi'o-'l
daces, by the continuous pain, an alteriition of the health which, afcJ
thia age, is nnt always compatible with 1'"

We must then resign ourselves to seeing the shortening persist^
We may try to oppose external rotation ; but if this opposition iai
painful we must give it up, and await recovery with the persistence
of this symptom also.

Pain is, above all, the thing which should be avoided in old people
affected with fracture of the neck of the femur. With thia object we
leave the patient in No. 6 for the present without any restraining, J
apparatus, and we apply linseed poullicea sprinkled with laudanum.*
We prescribed a soothing potion for the day, and half a grain of th»^
gummy extract of opium to be given if she suffers enough to make al
bad night probable. I

Furthermore, to avoid or diminish the pains which would be caused I
by movements, we have placed her upon a mechanical bed by meana
of which she can be raised for all necessary purposes without move
ment. If in a few days the patient complains of pain on the sacrum,
and if, as her leanness may make us fear, we see an eschar is immi-
nent, we shall place her upon a water mattress. The mechanical bed
and water mattress, gentlemen, are the two great means of alleviation '
and, for a certain number of patients, of the preservation of life after
fracture of the neck of the fern

After the inflammatory period has ended, say in about a week, if 1
tbe tenderness is greatly diminished,! shall phice the limb in seini-
flexion. I shall not simply use Dnpiiytren'a two large cushions, one
under the thigh, the other under the leg, for these cushions yield |
promptly and do not keep tbe limb flexed unless they are raised up
two or three times daily, an act which causes pain.

I shall use a double inclined plane of wood, made of two planka J
united at an angle, upon each of which will be placed a bag of chaff. -I
As soon as the limb has been placed upon it, a sheet rolled about the I
lower part of the leg, and pinned to the mattress or the aide of the bed,
will keep the foot in place after correcting its external rotation. T
place the limb in semi-flexion because I have noticed, without being
able to explain it, that in this position, rotation outwards was some-

I times corrected easily, and much better than when the limh was
Ktended. But I shall keep the patient in this position only if she 1
poes not suffer. I

You will meet with old people in whom the semi-flexion causes ]
prolonged pain either in the calf of the leg or in the groin. If our 1
patient presents this complication, I shall remove the double inclined I
plane, leave the limb extended, and content myself with placing a I
cushion nnder the outer border of the foot to raise it a little. Above ■
all, I seek to avoid pain, and to its dangers I prefer the slight incon-
venience of the persistence of the rotation. I have all the more
reason to prefer it, because the use of the double inclined plane gives
me only the hope but not the certainty of recovery without rotation. ,

As to the other patient, 1 found her with a Scultet bandage well
applied, and completed by a body band which partly immobiliaes the i

I 180 FRACTUEKS OF THE LIMB9,

^H pelvis. I left her in this apparatus after having examined the limb
^B and applied the mechanical bed. As the rotation of the foot outwards
^B ia not very great, and the fracture seems probably to be with pene-
^B tratlon, I shall not use the double inclined plane, and I shall continue
^H the Sciiltet bandage, but remove it if I hear the palientcomplain that
^^ it causes pain.

It goes without saying that the nourishment of the patients will be
as strengthening as circumstances will permit, and that the sacral
region will be wutcbed so as to prevent, by means of lotions of arg-
matic wine, starch powder, and cotton pads, the eschars whose
approach would be indicated by erythema and excoriations.

I shall not leave the patients in bed very long. The borinonta!
decubitus weakens old people, and predisposes them to pulmonary
engorgements. In about three weeks, if the pain hag diminished
sufficiently, I shall have them sit up in a chair. They will be lifted
out and put back by means of the mechanical bed with great precau-
tions. Experience has shown that these few movements do not
prevent repair from going on to the extent to which it is possible.

I shall give them crutches at the end of five or six weeks, and a
little later they will make use only of a cane.

LECTURE XXII.

FRACTURES OF THE LOWER EXTREMITY OF THE FEMUR-

I. Simple snpra-coniiyloirl fraolure — Fiinotioiisl und physical aymptoraB — Projection
fanTHrd. or tlie upper fragineiit — Impi^rfeot rednctioQ — Probable peiifltialjou — Con-
comitant artliritls. TreKtmvnt. II. Snpra-conctyloid and inter-t^ondyloid fiao-
tnre, Its prodiiotion by a nsdg«-tike niculiaiiiiam — Inflnenca of age upon tfaia
rdBolianisni and npoD tliis dlRgnosis — Rcduotinn impossilila. III. Supra- condy-
loid and intBr-oondyloid fraulore ooniplieated witb a wonnd aud projection Of
the end of llie upper fragment — Ainpntatiou — Ezaminstinii of the pieoa.

Gentlemen: I. Simple supra condyloid fracture of the right fenur.
— The patient in No. 15, 32 years old, told us that yesterday evening
he was knocked down by a wagon, and fell upon his right knee, lie
thinks he is sure that the wheel did not pass over his limb, and that
he simply fell in a false position, although he caunot say in what this
false position consisted. This, however, is certain, that after having
fallen he was unable to rise, that iie felt severe pain in the knee, and
was brought on a stretcher to the hospital.

This morning, after having removed the Seultet bandage which waa
applied yesterday, we found : —

Aa funciionai symptoms: 1st, The absolute impossibility for t^&

B FRACTURK8 OF LOWER B3TRBMITY OF FEMUR. 181

patient to niise his heel from the bed and to make anj movement
with hia right leg ; 2d. Quite sharp pain on pressure above the knee.

As physical symptoms : 1st, A moderate swelling, but with fluctU'
ation indicating an incontestable eEFusion in the femoro-tibial articu-
lation : 2d. An abnormal prominence, a little irregular, but not
pointed, at the anterior part of the thigh three finger- breadths above
the patella ; 3d. An unusual mobility in the transverse direction when
I moved the foot alternately outwarfls and inwards with one hand
whilst holding the centre of the thigh firmly fixed with the other.

I did not feel any crepitation, and, carrying my fingers behind into '
the hollow of the knee, I did not feel any abnormal prominence formed
by a fragment of bone.

From these symptoms I do not hesitate to assert that we are in
presenceof afractureof the lower extremity of the fsmar ^Malgaigne's
supra condyloid).

Ondoubtedly, the functional troubles which I mentioned, and the
considerable enlargement of the synovial cavity might have made ua
suppose it to be a violent contusion of the articulation,- a sprain, or ii
fracture of the patella. I do not admit the latter, because I found
neither interfragmentary separation nor abnormal mobility of thd
upper and lower halves of the patella, T do not absolutely reject the
idea of a contusion and a sprain ; but if these lesions exist they are
only a coincidence.

The main lesion is the fracture. The dominant symptom which
proves it is the abnormal mobility in the transverse direction. This
does not exist in the simple contusion ; it is true it may be found in
sprains of the severest kind, with rupture of the lateral ligaments.
But the mobility which we find here is not that of a sprain, for two
reasons: first, because it is much greater and more easily obtained
than is that of a sprain ; second, heoause the centre of these unusual
movements is plainly above the articulation. Add to that the abnor-
mal projection forwards of the upper fragment, which makea the
diagnosis still more positive.

I shall not try to give you any notions upon the etiology, for I
know hut little about it. The patient, as is always the case, cannot
tell U3 how ho fell. Ilis story permits us to infer that the fracture
was not produced by a direct blow. But how did the indirect cause
act, to produce a fracture at a point where the bone is so large and
so strong 7 This is what remains problematical. I am disposed to
believe that the lesion has been prepared by some alteration in the
bone, similar to that which takes place in old people in the cells oF
the cancellous tissue, and which gives this tissue a fragility greater
than at other ages. There may have been in him what I call prema-
ture senile alteration. But this opinion, which I oB'er here, as for
certain almost spontaneous fractures of the shad, is not thus far sus-
ceptible of decnonstratiun.

One word upon the displacement. Since we feel a projection of
the upper fragment forward, we infer the existence of a transverse
displacement with projection, which we can attribute either to the
direction of the fracture, or to the action of those parts of the triceps

i 'J

FBACTUBES OF THE LIM

which are inserted into the femur, I do not think that there is at
the same time longitmlinal displaGement or overriding; Cor I fonnda
diSerence of only a line or two in the length of the two limbs, and
this difference might be dueaa well to the dilfleulty of exact measure-
ment as to a real shortening. I presume that the fragments have
not slipped entirely' past one another, and that consequently shorten-
ing could not be produced.

I looked carefully to see if there was tipping backwards and down-
wards of the lower fragment, a kind of displacement which was indi-
cated by Boyer aa being habitual in this fracture, and which he
attributed to traction excited by the gastrocnemius. It seemed to me
that nothing like that existed here, that the lower fragment simply
extended beyond the upper one behind, and the upper fragmeot ex-
tended beyond the lower one in front.

Supra-condyloid fractures are not common enough for my own ex-
perience to enable me to know in what proportion this tipping back-
wards of which I have spolien appears. I have never met with it.
M. U, Trfilat' tells us that in nine cases, which he found described by
the different authors, this tipping backwards occurred only once. I
am, therefore, inclined to believe that it is rare. Eut aa it may occur,
I advise you always to see if it exists and if it does not exert, as it
may possibly do, an undesirable compression upon the popliteal
vessels.

The prognosis is simple, in this sense, that our patient's life is not
compromised; but it is uncertain, and may be had npon another
point, that of persistent deformity on account of irreducibility.

I told you that there was a projection forward of the upper frag-
ment. I add that I have made every effort to reduce it. While an
assistant, placed at the foot of the bed, made extension upon the foot,
and another held the middle of the thigh firmly to make the counter-
extension, I tried to push back the upper fragment with my hands
and to make this prominence disappear, but I did not succeed, I
repeated the attempt several times, and it always failed. It is
probable that I shall not succeed any better hereafter, and that,
consequently, consolidation will take place with persistence of the
transverse displacement. Fortunately, the prominence is not great
enough to endanger the skin ; fortunately, also, there is no consider-
able overriding, so that this deformity, iu reality slight, will have no
unfortunate consequences for the functions.

But to what is this irreducibility due? To an anatomical dis-
position which I have told you is often found iu fractures of the
extremities of long bones. To the penetration of the lower fragment
by the posterior part of the upper one. M. U". Tr^lat has shown
clearly that there is often crushing of the spongy bone found here,
as there is in the lower extremity of the radius and in the neck of
the femur near the great trochanter, and that one of the points on
the circumference of the long fragment penetrates into the body of
the lower one, and lodges there in such a way that it cannot be

FRACTURES OF LOWER EXTREMITY OF FBMUR.

183^

disengaged, I do not mean to say tbat penetration always take!
place in the supra-condjloid fracture, nor tliat, when it does so, it ioM
always irreducible ; I only say that it happens often, and that it hiU
happened in this case.

The prognosis may be bad in another way, that of conseontivefH
arthritis. I do not believe that the fracture sends a fissural prolongaij^
tion towards the articulation of the knee. Still, it is not impossiblqi?
But the fracture is so near the articulation that, by proximity, thef
latter is already affected and full of liquid. .

If we find arthritis of the knee after almost all fractures of the
shaft of the femur, so much the greater reason is there for it to appear
when the lesion, without being articular, is so near the joint. It is not
that I fear that which would be more dangerous, suppuration. Sueh a
termination, strictly speaking, would be possible; but we find it ed^J
exceptional after simple fractures that there is no reason to fear
in the present case. Still, non-suppurative arthritis is the raore^
severe and the more likely to leave behind it a prolonged stiffness, orl
even incomplete anchylosis, as the articulation is nearer the infiamecl' j
seat of the fracture. This part of the prognosis in this case
diminished, it is true, by the circumstances that the patient is youn^
and apparently neither rheumatic nor gouty. But, nevertheless,
cannot guarantee that he will not have a false anchylosis, and thsrf
the means with which we can oppose this result will be snccessful. .
Upon this point we should always warn the patients or their friends,
ao tbat they shall not accuse us, as so many people are disposed to
do, of having allowed, through insulBeient oare, this false anchylosis
to be established.

Treatmenl. — At present we have but one thing to do: set the
fragments as well as possible, and keep them in place. I applied,
this morning, the Scultet bandage, with which you are acquainted,
I after having made, unsuccessfully, some attempts at reduction.

In a few days I shall renew these attempts, and again once more D

. ew days later. If I should succeed in replacing the upper fragmentfl

Is shall add to my bandage anterior compre.saos intended to keep this

pliragment in place; if I remain unsuccessful, which is most likely, I

ill content myself with the same dressings, and I shall not think

t^»r a moment of applying any apparatus for making contlnuotia

stension,

I expect consolidation to go on more rapidly than in other fractures

r the femur, for two reasons: first, because, ordinarily, the callui

tbrms more rapidly in the spongy than in the compact ti.ssue; and..

scondly, because the circumstance of a persistent penetration favours J

^his rapidity. W

\ If, at the end of four or five weeks, I no longer find abnormal'

(nobility, I shall remove the apparatus and leave the limb free, I

^all not let the patient get up; for it is probable that the callus,

Slough solid enough for the horizontal position, is niit sufficiently so

support the weight of the body. But I shall tell the patient to

move his knee a little while lying in bed ; I shall, myself, communicate

movements to it every morning, and I hope that this little

hiB
,1

nk
jtia ^^

ires^H

lIuti^H
ind^^H
mra^^^l

mal^^^'

184 PRACTCRBS OP THE LIMBlJ.

exercise will prevent the formation of an ancjhylosia, and favour the
restoration of motion. Yon know tl:at thia stiffness after fracture ia
due partly to traumatic arttiritis and partly to prolonged immobility.
It is to diminish tlie inHuence of the latter that I shall remove the
apparatus early, and have recourse immediately to communicated
movements. I shall thu3 leave only the influence of the traumatic
, but it is true that thia influence is so great that I always fear
a notable and definitive loss of part of the normal raovementa of the
articulation.

II. Fracture, sup-posed to be supra- and inler-condyloid, of the lower
extremity of the left femur. — Here is a man 59 years old, of rather
feeble constitution, who fell three days ago upon his left knee, from a
stool upon which he was standing to unhook a curtain. When
brought to the hospital, yesterday only, he presented the following
symptoms: —

Decubitus upon the back; left leg extended, without rotation out-
vards ; inability to raise the heel from the bed ; pain at the knee when
he tries to move, when movement is communicated, and when the
articulation is pressed upon.

The knee is very swollen, and evidently fiuctuating; it seems en-
larged, and when, raising the foot, we move the lower part of the leg
laterally, we feel a very marked abnormal mobility, the maximum of
which is evidently above the line of the articulation. It is difReult
to feel the patella, because above and a little in front of it is an abnor-
mal bony prominence which is clearly continuous with the abaft of
the femur. There is also shortening of the limb to the amount of IJ
inches.

You recognize from these symptoms a fracture of the lower ex-
tremity of the femur. But here I have every reason to think that the
fracture is not only supra-cundyloid but at the same time inter-condy-
loid, that is to say, that in addition to the line of fracture which passes
above the condyles, and which, from the projection forwards of the
upper fragment, runs obliquely upwards and backwards, there is a
vertical line which passes through the inter-condyloid notch, and
separates the two condyles from one another.

The only piiysical sign upon which this diagnosis is based, is the
transverse enlargement of the knee, an enlargement which I .suppose
to be due to a slight separation of the fragments from one another;
but I was unable to detect any abnormal mobility by gnisping each
condyle and trying to move it backwards and forwards. If, as I be-
lieve, the condyles are separated, they are still so firmly held, either
by the ligaments or by their connections with the upper fragment,
that they cannot be moved separately.

But if I have no other physical sign to support my opinion, I find
a probability which is very nearly a certainty, first in the age of the
patient, and then in the ideas we have gathered from the examination
of several pieces, and from our studies upon the mechanism of wedge-
shaped or V fractures.

I say the age of the patient; for, in several pieces which I hove
examined, in one, umong others, which I presented to the Soci^de...

i OF LOWER ESrRKMlTTOF FEML'R. ISfif

IFRA
-Chirurgie, the 2l8t Nov. Ii355,'and which I recalled in a report upoa
'||be works of M. hv£& in 1858," fracture at the same time supra- iind
inter-coD(lyloid was obBerved in patients who, like this one, were
more than fifty years old, that in, had reached the period of life in
whkh the spongy tissue of the bone has undergone those modifica-
tions which render it more fragile and more liable to split under thg
influence of violent pressure.

I demonstrated distinctly in these same pieces, by bringing the two
condyles together, that there was a depression or loss of substance
into which the oblique and more or less pointed extremity of the
upper fragment passed. It was sufficient to put the pieces in place
to see that, at the moment of the accident, the upper fragLoent must
have penetrated into the lower one, and, acting upon it like a wedge,
split it idl the more eiiaily because at this point (the inter-condyloid
notch) the lower fragment is very short. Parsuing, in a word, the
studies upon penetration made by M. Voillemier* lor the lower ex-
tremity of the radius, and by Alpb. Robert for the upper extrsmily
of the femur, and those which I had made for V fractures with
secondary lines resulting from the pressure of one of the main frag-
ments upon the other, I showed that complex supra-condyloid and
inter-condyloid fractures belonged to these varieties (fracture by
penetration, wedge fracture), of which our predecessors did not make
Bufficient mention, and which M. IT. Tr^ht alone had pointed out,
without dwelling upon them long enough to make our ideas clear
upon this subject. It is to give you precise ideas upon it that I re-
mind you, whenever the occasion presents itself, that this mechanism
■ of penetration is intimately united with that of crushing, that both of
^hem intervene in most fractures of the cancellous extremities in old
_»eopIe, and that the wedge action, the consequence of the penetration
jhnd crushing, intervene also in these same conditions, and add the
jsion which causes the fracture to communicate with the neighbour-
nng articulation.

To recapitulate then, we have here, in all probability, an articular
"i'racture of the lower extremity of the femur, with projection forwards
of the upper fragment, and overriding.

Is this fracture reducible? You saw that in making the manceu-
vrea of extension and counter-extension, I strove in vain against the
displacement, and that I was able neither to restore to the limb its
length, nor to cause the projection of the upper fragment to disappear.
If I meet with the same obstacles in the following days, and it is pro-
bable that I shall, I shall find myself once more in presence of an
irreducible fracture. Do not be surprised at it, gentlemen; irreduci-
bility is a consequence, I do not say inevitable, but very frequent, of
these fractures with penetration and secondary splitting of one of the
tfragments by the wedge-like action of the other. In certain cases it
B due to the fact that the long fragment remains lodged within the
■hort one, and is kept there by a kind of connection for which I find

■ Ooswelin, Bulletin de la SooifilS de Cbimrgie, t
' Lize, Baltetiii de la Saciae da Cliirargia, tome

■ ToUemier, Ctiniqau CLlrargiuaie, Fatla, IHSl.

186 FRAOTURttS OF TH

H 18'

^1 no other word tbnn interlocking. This is not exactly the case today;
^H for the projecting portion of the upper friigment is so voluminouB
^M that it has evidently iibandoned, at least in great port, the lower frag-
^m meat after having split it. It may be, however, that the posterior
^B portion of the first is ndherent by some irregular points, and by menus
^M of adjoining fragments, and that thesa prevent reduction. It is pro-
^M bable that the principal obstacle ia caused by muscular resistance, as
^m in a certain number of fractures of the shaft of the femur, while the
^P obliquity of the main line of the fracture, and the pulverization and
. packing of the cancellous tissue of both fragments, favor and render
irremediable the shortening produced by this muscular action.

I do not mean to say that all supra- aud inter-condyloid fractures
are as irreducible as this one is. I say only that it is quite frequent,
and that in our pre.'^ent patient it is as marked as possible.

You understand the prognosis: the patient will recover with con-
siderable shortening, and the arthritis will be all the more severe, pro-
longed, and likely to end in anchylosis, because, on the one hand, the
fracture communicates with the articulation, and on the other, the age
of the patient predisposes to prolonged arthritis and anchylosis.

As to the treatment, it will consist of repeated attempts to make
reduction, and of the application of a Scultet bandage which I shall
maintain so long as the abnormal mobility lasts. I fear the consolida-
tion will be slow, because only a small part of the upper fragment is
in contact with the lower one, and this disposition is not favourable to
the formation of a callus,

III. Supra- andinler-condijhid fracture with wound and prnjeciioTi of
the end of the upper fragment. Amputation of the thigh. — The patient
whom we saw at No. 25, and who is 51 years old, was caught yester-
day by the caving in of some earth, and, after a moment's struggle,
was overthrown, feeling at the same time severe pain in his left knee,
but without knowing how or in what position the knee wits injured.
We find the parts in the following condition: —
Through a wound in the anterior portion of the thigh above the
patella, projects the upper fragment of the femur, which ends in a
hard point. About this wound there ia no occhymosis and no effusion
of blood. The articulation is swollen and fluctuating. There is very
marked lateral mobility, and an enlargement of the transverse diameter
of the knee, with inability to move each condyle separately, back-
wards and forwards.

We have evidently here, a compound supracondyloid fracture with
issue of the upper fragment. I add, that for the moment this frag-
ment is irreducible, for I have made fruitless attempts to return it to
its place. It is also very probable that the fracture is at the same
time inter-condyloid, and that consequently the external wound com-
municates both with the seat of this fracture and the cavity of the
articulation. My reasons for thinking so are, the broadening of the
knee, the abundant and rapidly formed effusion within the articulation,
the form of the upper fragment which is well fitted to penetrate and
act like a wedge, and finally the age of the patient. This diagnoalfl
leads to a v%fj serious prognosis.

I FKACTUKKH OF THE SHAFT OP THS FEMUR.

A large wound like this will inevitably suppurate, and it is ala^
inevitable that tlie suppuration will extend to the fragmenta of boiM'
and the articular cavity. Now this suppuration in a hospital, upon i
man who is quite old, has every possible chance of terminating iffl
putrid iufection during the first few ditys (grave traumatic fever), <
in purulent infection, and in any cnse by death. Although amputa
tiou of the thigh is also dangerous, and although amputation for S
traumatic cause especially yields only rare succe.sses, yet I considel
that this operation is a little less likely to be followed by death thai^
an attempt to preserve the limb would be. That is why I prefer
amputation : the patient accepted it, and we shall now perform it.

This will be an amputation of the kind which M. Hip. Larrey called
primilive, that is, one which is performed before the development of
the traumatic fever. K we should wait until this evening
morrow, this fever would undoubtedly be established, and the patieng
would be in a much less favourable condition.

(We found on examining the piece, that the fracture was iuter-coDia
dyloid as well as supra-coudyloid, and that consequently the wountf
and the seat of the fracture communicated with the articulation. Th^
patient succumbed on the twelfth day, to a purulent infection whiol
Laucceeded a very intense traumatic fever.)

LECTURE XXI IT,

■y. CousidBrations upon spnntsnoouafractareH^Tlieyar
— This 13 onuSBd aoraetiines by a oanoer, Bometime
times by premalure Ballils carefaotion — Case of b
a Bob- 1 roch ante Ha fractare of Uia femiir — Kol
9 In tlia Hapttal Coohin. II. ItdratiTe fractart

dga to an abnormal tragiliti

by a rarefying osteiti:
patient affeotpd with spent*
irt's aiialogooB case — AnotliM
of tba left femur, dm

keeping the bed long enaagh — Usane oF avoldiag this accidaat.

Gentlemen; I. Spontaneous fractures. — We have the habit of
giving the name spontaneous to fractures which are produced so easily
that they seem to occur without the intervention of any appreciable
cause. Notwithstanding our habit, this designation of spontaneous
is not absolutely exact, for in reality we can always attribute the
solution of continuity to muscular contraction or the weight of the
body. But when it is a question of a bone ao voluminous and so
strong as the feraur, of a bone which serves for the attachment of
powerful muscles, and to support the body when standing or walking,
you will admit that it is allowable to consider as almost spontaneous

fl88 FBACTURB3 OF THE LIMBS.

fractures which hnve do other cause than the aocomplishmen I. of the
funciiona of this bone.

It 13 siilficient to consider the physiological resistance of the femur
to understand that if in certain exceptional cnsea it yields so easily, it
ia because thia resistance has been weakened by a modification of its
Btructure.

This i,9 very evident when the fracture ia consecutive to an oateo-
Barcoma.

frir example, at the Hopital Cochin, in 1857, a woman 60
years old, who had been admitted for a tumour, larger than tlie fisi,
occupying the entire circumference of the right femur, and which we
had recognized as a cancer of this bone. A few weeks after her

.mission to the hospital, they told me, one morning, that she haif
complained durin<^ the night, after a movement to turn in bed, of a
very sharp pain, and that since then the pain had not ceased. On
reaching her bed I found her with the foot and leg in outward rota-
tion, and with very marked mobility at the point occupied by the
tumour. There was no doubt that the cancer had gradually destroyed
the bone, and that at laat the femur was no longer strong enough to
bear without breaking even a movement in bed,

I saw a similar case at ths HSpital des Cliniques, in 18i8, in a man
65 years old, who had broken his left femur while getting out of bed,
without any other accident, and in whom the fracture took place at
the seat of an old cancerous tumour which occupied the femur and
had been indolent up to that time.

But the explanation of the loss of strength by the femur at some
point in its length is more difficult to give in case.^ like the one before
us, in No. 10, Ward St. Louis (Hopital de la Piti^).

The patient, 30 years old, of vigorous appearance, has been under
treatment here for more than 80 days, and in another fortnight will
leave us to go to Vincennes.'

When we first saw him he was in a medical ward where he had
been placed because they had no reason to suspect the existence of a
surgical lesion. He told us that while walking tranquilly across the
Grenelle bridge, and without having made any false step, he felt a
sharp pain at the upper part of his left thigh. He then sank down
gently, and waited until two passers-by came to help him.

Finding himself unable to walk, he was carried to the Central
Bureau, and thence forwarded to a medical service for thia pain which
was supposed to be rheumatic.

Having been asked to examine him, I found rotation outwards,
shortening of the limb to the extent of an inch, and abnormal mo-
bility with crepitation in the upper third of the thigh below the
trochanters. The patient was then brought to my ward, later exami-
nations confirmed the first impression, and it became more and more
evident that this man (who before this time had not been lame, and
had a well formed limb) had auEfered while walking, without falling,

s pablisbuil in the Snz<:tt« des llOpUani, Glh

FRACTURE;

SAFT OF TBB FBMQR.

anrl without having received any external violence, a sub-trochanterie
fracture. He assured us, moreover, and those who brought him here
confirmed the statement, that he was not intoxicated at the time of
the accident, and that he was perfectly aware of all that took place.
We were then justified in believing that this was a spontaneous frac-
tnre. But was not this fracture the consequence of a cancer? We
felt no appreciable tumour. If there was a cancer, it was one of those,
hidden ones of the medullary canal which it is permitted to suspei
but the existence of which can be demonstrated by no physical signv.
Moreover, the age of the patient and his vigorous constitutiun dia^
■TOissed the idea of a cancerous aftection. But if it was not a cancef
Jwhich had weakened the femur, it must have been another lesion; ■
irhat was it? Search through the records left by our authors doeft!
lot enable me to give you a precise answer; for they have not at-
tempted to explain the cause of the fragility of certain bones, and"
'ley were not able to do so, for the simple reason that examples of
t are very rare. In those which have been presented, no autopsy
Ks been made; it was necessary to be satisfied with the clinical fact
(rhich, in itself alone, as in our present case, did not clear up the
^■pathogenic question.

Malgaigne spoke of a peculiar osteitis which causes fragility of the
bones, and explains these fractures which are so easily produced.
But, as I shall have occasion to tell you when speaking of other
fractures by muscular contraction, I would believe in the interven-
tion of this osteitis if our patient had suffered for any length of time.
Malgaigne appears to have observed these spontaneous fractures io
patients who had had these sufleriogs, and that is what justifies the
expression of the opinion. I was able to attribute the fracture to aa
osteitis in the case of a patient of whom Alph, Robert spoke in his
_ lectures,' and whom I treated at the Hopital Cochin, because this
Mitient had had for two years continual pains in his lower limbs.
But when, as in our present patient, there has been no pain of this
^fcind, must we admit, nevertheless, rarefying osteitis? I think not.
r if I understand rarefaction of bony tissue coinciding with an
Sateitis, I also understand, very well, rarefaction without osteitis, and
y a peculiar vice of nutrition analogous to that caused by age, whence
i name premature senile rare/action or alteraiwn. which you have
lard me use quite often.

Is there not, at least in this patient, some constitutional cause which
wight explain the rarefaction 'I I know none. I have given par-
"tleular attention to the possibility of constitutional syphilis. Now,
OQ the one hand, it is claimed by nobody that syphilis causes fra-
gility of the bony tissue; on the contrary, it rather increases their
solidity by producing hyperostosis and exostosis; on the other hand,
r patient shows no trace of syphilis, and says he has never had it.
was the same with the case at the Hflpital Cochin. It is true that
t gave him the iodide of potassium ; but I administered it as a forti-

I Robert, Coiittre

e Cliuiijue CUirurgicale, 1860, p, 4

[ 190 FRACTURES OF THE LIMBS.

fying and not as an antlsyphilitic measare. It was tlie same in Rob-
ert's caae.

I call yoor attention to another point.

This fracture occupies tlie upper third of the abaft, and deserves the
name of sub'trochanteric.

Tt occupied the same place in my patient at the H6pitnl Cochin,
and also in Robert's patient. Has the upper portion of the shaft of
tbe femur a special predisposition to this singular alteration of nutri-
tion which causes fragility ? Three cases are not enough to give ua
any certainty upon this point, but it is allowable, at least, to mention
the peculiarity.

Prognosis. — When I began the treatment, I did not know if wo
abould get consolidation. For if the fragility had been due to a bid-
den cancer, tbe callus undoubtedly woalJ not have formed, and in
case of premature senile alteration, there was also reason to fear that
materials for the calUis would not be furnished, or would not be pro-
perly elaborated at this affected portion of the skeleton.

Still, as the callus had formed in my patient at the Ilopital Oochio
and in Robert's, and as this patient was of a vigorous constitution, I
had no reason to despair.

The fact is that the consolidation was obtained in the ordinary
length of time, and that to-day, three moaths afterwards, not only do
1 no longer find abnormal mobility, but I feel a large strong ciillus,
which makes me think that at the place occupied by the bony altera-
tion, tbe traumatic inflammation excited a nutritive movement, and
restored, perhaps even in excess, the normal strength of the bone,'
that is, notwithstanding the presumed pre-existing rarefaction, this
traumatio osteitis has taken on the condensing form which we see so
often after fractures of the long bones.

The fears whicb I might have had on the subject of non-consolida-
tion have been justified by the case of a patient whom I have since
seen at the U6pital de la Chariti?.

It was a woman 52 years old, much more feeble and broken down
than is usual at that age. A few months before her admission to the
hospital she had broken her right humerus by a very simple fall from
a standing posture, and had recovered ; a little later she had broken
the shaft of the left femur below the trochanters, as in the three
patients of whom I have spoken, and so easily that she did not know
exactly to what accident to attribute it. For she had fallen three
months before in her room while walking slowly towards the window,
and a few weeks afterwards, while turning in bed, she bad felt very
sharp pain in her thigh, and she was unable to say whether it had
been broken by this latter movement or by the antecedent fall.
However that may be, the thigh presented shortening, rotation out-
wards, and very marked abnormal mobility, symptoms either of a
fracture still too recent to have become consolidated, or of an old
non-consolidated fracture. This woman died of exhaustion in May,
1868.

FRACTUHES OF THE SHAFT OP THE FEMUR. 191 ]

We found at the autopsy, below the trochanters, a false articiilation,
consisting of a fibrous sleeve, quite thick but not ossified, in the cavity
of which the two fragments were found at a certain distance from one
another.

It 13 evident that the fracture dated from the first accident of which
she had told us, and thnt it had not consolidated. Above and below
ihe vacuoli of the cancellous tissue of the femur were very notably
mlarged, the compact tissue was thinned, and a moderate pressure
uPfiuieiit to split the bone which was remarkably fragile in con-
sequence of the absorption of a part of its bony substance. There
was no trace of cancer of the bone. The right humerus, which had &
solid callus with obliteration of the medullary canal, was nevertheless
very fragile below the fracture.

We had then, in tliis case, the example of two almost spontaneous

ictures; one of the humerus which had been followed byconsolida-
;on ; the other of the femur which was not consolidated ; hence the

■ncluaion that in cases of this kind consolidation is possible, but
.ay also fail.

II. Itemtive fracture of Ihe left femur. — I called your attention to
'o. 2, a young man 19 years old, who has been under treatment
here for 50 days, for fracture of the shaft of the femur below its cen-
tre. Aa the callus seemed to be very solid on the 4.5th day, and as I
no longer found any abnormal mobility, and as, furthermore, I did
not wish to keep his knee immovable for too long a time, I removed
the Scultet bandage. But I had expressly told the patient not to get
up, intending to keep him in bed until the 70th or 75th day, and then
4o make him begin with crutches. But this is what happened: the
pay before yesterday, the 48th day since the accident, he got up aud
walked a short distance, supporting himself on the adjoining beds.
Ee slipped, fell, and broke the callus. The next morning we found
abnormal mobility and crepitation as at the beginning, aud the patient
RVas again unable to raise his heel from the bed. I reapplied the
Beiiltet bandage, prescribed 30 grains of the phosphate of lime to be
token twice a day, and told the patient be would have to remain in
Bed for three months.

ft This is not the first time I have seen this rupture of the callus, or
Kerative fracture; I saw two other examples of it a few years ago;
Rie at Cochin, the other at Beaujon, and both of them were young
Ken whose apparatuses I had removed about the 50th day, forbidding
Biem to leave the bed, but both had disobeyed aud had fallen in the
Vards.

y The first thing to be remembered from these facts is that the callus
Day acquire by the 45th to the 55th day, sufficient solidity to prevent
pommunication by our bands of the movements which are patbogno-
Bionic of the persistence of the fracture, but nevertheless not be solid
fenough to bear either the weight of the body or an inflection during
i fall.

y For you observe that I do not know if, in my three patients, the
Ihtcture was produced by the fall, or if the fall was the consequence
&f the rupture of ibe callus uuder the infiueuce of the weight of the

1192 FRACTORES OK THE LIM

body. However that may be, the practical ooneluaion is that the
patients must not be allowed to get up as soon aa we flud immobility,
and we muat wait for at least the 70th day before allowing them to
leave the bed. Until that time, the callus, although it no longer
shows abnormal mobility, is still too fibrous or too little bony to
resist an unexpected impulse or inflection. For it is only peripberal
and not interfragmentary.

Let us remember another fact, that these iterative fractures are to
be feared, especially in young people (and it would undoubtedly be
the same for children). The callus certainly forms a little more ra-
pidly at this age than in adults, bat it needs, none the leas, from eight
to twelve weeks to obtain the solidity necessary for walking. Now,
we can easily persuade an adult to remain in bed a fortnight afterthe
apparatus has been taken off. During this time, we use friction, mas-
sage, and communicated movements, to correct the stiffness of the
knee and foot.

But it is much more difficult to keep a young man in bed after he
has been relieved of the restraint of his apparatus, and you must not
expect them to obey your i nstructions upon this point. Consequently
the wisest plan in their case is to leave the apparatus in place until
the ftSlh or 70th day, while in adults upon whose reasonableness you
can place more reliance, yon may remove the apparatus from the 50th
to the 60th day, and let them walk a fortnight afterwards. The dis-
advantage of the more prolonged immobility in young people is
compensated for by their lesser aptitude for anchylosis and the pro-
longed stift'ness of the concomitant traumatic arthritis.

In children, until the age of fifteen years, I advise you not to leave
the apparatus on longer than the 45th day, because consolidation
goes on more rapidly ; but it is still prudent, in order to avoid itera-
tive fracture, not to let them walk, even upon crutches, before the
60th day.

You will not often have occasion to see the callus break a second
and a third time, because, warned by the first rupture, you will take
care to recommend sufficient rest in bed and phosphate of lime, which
will ensure a solid recovery. If, however, the patient does not obey
your instructions, the fracture of the femur may bo reproduced three
or four times.

I was consulted in 186-i by a young man from Saint-Pierre Calais,
25 years old, who had broken his left femur six times in the course
of twenty months. A remarkable fact in the case was that the frac-
ture did not occur when he began to walk, but from the 8th to the
15th day afterwards, and generally in consequence of a slight effort,
either to save himself from falling, or to run. Once, indeed, the
fracture took place while be was dancing. Each time the patient had
been allowed to get up on the 45th day. He had reached the 40lh
day of his sixth and last accident, when his father came to I'aris to
consult me upon the means of preventing these iterative fractures. I
told him to keep on the Scultet apparatus, which had been applied,
for two entire months, and not to allow the young man to leave his
bed until the end of the third month, and to give phosphate of lime

FRACTURES OF LOWER EXTREMITY OF RADIOa.

daring the whole time. These prescriptions were followed and the.
fraeture was not repeated,

I saw the young man himself iu November, 1869, at Saiat-Pierre,
where I had been called to see another patient. He had remained
perfectly well, but with a shortening of 2^ inches, a limp, and the
necessity of using a cane, all of which did not prevent him from
walking a great deal, even far several leagues at a time, without difH-
enlty.

19S^^|

the^l

LECTURE XXI Y.

~ PRACTURES OP THE LOWER E.tTHEMITY OF THE RADIUS.

ipnaecutiTB and late plienoiuBua. I. Firat pallent on Llie fiftieth day ot the fracturB
— Study of tlia aliape and [unclioiis — Kiglditf of the articular aynovial u
btanes, due ta artbritia by proximity In the wrisl, and arthritis by immobility J
In the fingers — Rigidity of the teiidltious syiiovlal memhrsnes. 11. Aiioth«e>|
patient (woman S9 years old, ninetieth day) — Slower and parhapa impo33ihli<^
reooTery from the eame rigiditiea ou aocoant of her advanced age.

Genti.Emen: I have brought to the amphitheatre, that you may
■*1I see them better, two patients who have been treated in our wards
for fractures of the lower extremity of the radius. One of them is a
man 38 years old, the other a woman 69 years old.

I. The first has reached the fiftieth day of his accident. I treated
him for five days with poultices, and at the end of that lime applied
Malgaigne'a apparatus, which you often see me use, with a cottoa
cushion upon the posterior part of the lower fragment, and another
upon the anterior portion of the upper fragment ; over these a gradu-
ated compress, and a splint upon the palmar surface of the forearm
and hand, and graduated compress and splint upon the dorsal surface ;
the whole kept in place by means of three bands of diachylon a yard
^nd a quarter long and an inch wide. Of course before applying
^iH apparatus I had done my best to make reduction by the mancen-
a of extension, counter-extension, and coaptation. You remember
Be bandage was removed a fortnight after its application, that is, the
Veuty-first day after the accident, and that the patient left us three
'f four days afterwards.

He returns to-day, the fiftieth day after the fall, to consult us for per-
sistent trouble in the band. I call your attention to two principal
points; the shape and the functions.

1. The shape of (he wrisl and forearm. — At the wrist our eyes detect
no irregularity and no trace of the characteristic silver-fork deformity
whicli existed at the beginning. But by comparing this region with
that of the other side, we find it is a little larger, and if we then
_ 13

I
I

194: FRAOTURKa OP THE LIMBS.'

of it, so 3,3 to better appreciate the difference, we find under the akiu
a superficial and general induration which can be due to nothiug else
than the swollen radius. We have then here another example of
that variety of bone lesion which so often follows suppurative or non-
suppurative osteitis, and which we find especially in non -scrofulous
subjects, that is, hyperostosis. I next compare Che relative positions
of the two styloid processes, and find them the same upon both sides.
I therefore infer that the styloid process of the radius, which under-
went a slight ascension at the time of the accident, has been restored
to its place by our manoeuvres to make reduction, and has remained
there. I am pleased with this result ; for in many cases, after fracture
of the lower extremity of the radius, the styloid process remains higher
up the arm, so that its point is upon the same transverse line with that
of the ulnar. The reason of this is that, the fracture being with pene-
tration, the two fragments cannot be separated from one another at the
moment of reduction, or else that, reduction having been made, absorp-
tion of that part of the spongy tissue which was most crushed at the
time of the accident has taken place between the fragments before
consolidation. I suppose that in our patient, who is still young, the
spongy tissue had not undergone before the accidept the rarefaction
which predisposes both to reciprocal penetration in cases of fracture
and to considerable attrition. That is why the radius has recovered
almost its normal length. I find in this condition of affairs the advan-
tage that the articular surfaces of the lower radio-ulnar articulation
are not so much deformed as when there is permanent ascension of
the lower fragment and diminution of the length of the radius. This
condition is favourable to the ultimate restoration of the movements
of this articulation.

Finally, to finish with the shape, I ask you to compare the volume
of the two forearms. The left one is a little smaller than the right,
and the difference is due to the smaller size of the muscles. This then
is another example of the slight and unimportant, but still real, mus-
cular atrophy which follows almost all fractures of the long bones,
and of which I so often have occasion to speak.

2. The functinns. — As for the functions, you see that this man can
execute without pain the movements of flexion and extension of the
wrist and fingers. But you also see that these movements, especially
those of flexion, are more limited than in the normal condition, and
that in this respect they are far from being what we desire. The
patient also says that he has but little strength in his hand, can carry
nothing with it, and uses it very little, even in dressing himself. I
now ask him to make the rotary movements which give pronation
and supination, and you see that they are incomplete, that they
scarcely take place at all in the lower radio-ulnar articulation, and
that they are executed almost exclusively at the shoulder.

How can we explain this diminution of the movements and the
weakness of the limb which is the consequence? It is not due to
the insufficiency of the muscles ; for, on the one hand, the atrophy of
which I have spoken is slight, and, on the other, we often see atrophy
of this kind, and we know that it does not diminish the extent of the

FRACTURES OF LOWER KSTBKMITT OF RADIPS. 195-

moveraents, since the muacular fibres cootinue to receive from their
nerves, which have remained intact, the impulse necessary for their
contraction. That which explains this functional trouble is especially
the rigidity and the insufficient extensibility of the articular and tendi-
noua synovial membranes. As for the first, those placed near the
rest of the fracture have participated in the inSammatory process, and
have lost, in consequence of the traumatic inflammation of which they ^^H
have become the seat, a part of their extensibility and suppIenesft^^^H
These are the radio-carpal, the carpal, and lower radio-ulnar synovial^^H
membranes. The others, placed further from the fracture (I refer to ^^^
those of the fingers), have not been inflamed in consequence of their
proximity; but we have the right to believe that they have become
altered and modified as a result of tlieir immobility. You remember
that M. Teissier, of Lyons,' published a work upon the effects of pro-
longed immobility of the joints. But he did not make a distinction
between the large and small articulations- Now, the first may remain
immovable for several weeks, and even for several months, without
losing the natural suppleness and extensibility of their synovial mem-
branes. Notice patients who have had a fracture of the leg or of the
thigh; the knee-joint in the first, and the hip in the other have
remained immovable for a long time, and yet the moment you cease
the treatment you can communicate extended movements to them,
and without finding much resistance. The large articulations become
rigid only when consecutive inflammation has invaded them, as takes ^^m

Elace quite often in the tibio-tarsal articulations after fractures of the:^^|
}g, and always in those of the knee after fractures of the thigh. ^^H

It is not the same for the small articulations of the fingers. They ^^B
are too far from the radius (and, moreover, the same thing follows
fracture of the shaft of the forearm or of the humerus) for us to admit

the propagation to them of the phlegmasia developed at the seat of i

the fracture. If they become rigid, it is the immobility alone which ^^M
is the cause. In consequence of their inaction, their synovial mem< ^^H
branes have become dry and shrunken, and have tost their supple- ^^H

P"i3s. That is why they oppose flexion of the fingers; and if a littlo ^^^
roe is used, the stretching to which they are subjected causes .^^|
^1
As for the other synovial membranes, those of the tendons, it is ^^|
probable that that of the extensor tendons behind, and the great car-
pal one of the flexors in front, have been attacked in consequence of
their proximity to, and by propagation of the phlegmasia which is
developed at the fracture, and that, consequently, they have become
rigid. I do not deny that the immohihty may have contributed to a
certain extent to this result. But basing the opinion upon the fact
that immobility alone does not cause rigidity of the large tendinouS'
synovial membranes when a centre of irritation, like a fracture op
dislocation, is not near them, I am inclined to believe that most of
the rigidity is due to synovites by propagation.

Do not be surprised at these results, gentlemen ; they are very com-

, OaietteHaJIcalH, 1841.

196 FRAOTOBEH OF THK LIMBS.

mon, and you will often meet with them in practice ; indeed, you
must even take care to forewarn your patients of them, that they may
know that the difficult movementB of which they will have to com-
plain for a long time after fracture of the lower extremity of the
radius, are not due to insufficient or unskilful treatment, but are a
consequence of the disease itself.

Moreover, I tell them not to worry, for all these functional troubles
will disappear in time. The articular and tendinous synovials will
recover their polish and then their suppleness by use, and it is very
probable, if I may judge by the facta of the same kind which 1 have
observed, that iu three or four months the movements will have re-
covered their natural extent and ease. Those of pronation and
eupinatiou will be the slowest to return, but I expect their perfect
return all the more confidently, because the radio-uloar articular sur-
faces are not notably deformed. This relatively favourable prognosis
is further justified by the fact that the patient is young and not rheu-
matic ; you remember that those are favourable conditions.

As for therapeutical advice, I shall tell the patient to communicate
moderate movements with the other hand to the fingers and wrist,
and to apply friction every morning and evening with pure lard, or
lard mixed with alcohol, and to take two sulphur hatha every week.

II. The other patient is a woman 69 years old. Her fracture waa
received three months ago, and you can see that notwithstanding the
length of time that has elapsed, the shape and fuactions leave rauoh
more to be desired than in the preceding case.

First, the ailver-fork deformity is still quite marked, although at
the time of the accident I made the manceuvres of extension, counter-
extension, and coaptation, and employed the same apparatus as for
the other. Moreover, the styloid process of the radius is higher than
it should be. Its summit is on the aa me transverse line as that of the
styloid process of the ulna. What is the reason of this faulty con-
formation ? It ia due to two causes : first, to thia that the age of the
patient having caused rarefaction of the cancellous tissue of the lower
extremity of the radius, this tissue was crushed by a fall upon the
baud, and then, as described -in the excellent study of thia accident
by M. Voillemier,' the fragments penetrated one another, and became
so interlocked, that my eflbrta were powerless to change their recip-
rocal positions. Second, it is probable that part of the crushed bony
tissue waa afterwards reabsorbed, which would diminish the chances
of a permanent return of the lower fragment to its proper place.
Consolidation, nevertheless, took place, because, as I have often told
you, consolidation goes on well and rapidly in the cancellous tissue
of most long bones (I except intra-capsular fracture of the neck of
the femur); but the callus has remained irregular for the reasons
which I have just given.

As for the functions, you heard this woman complain of paina
which ahe feels when at rest, and which increase when she tries to
move the wrist and the fingers. Voluntary movements are very

hirea OSiieralea do Miyeeine, 1S42, tome sili. p. 261.

FRACT0RKS OF LOWER EXTREMITY OF RADIOS. 197

limited, as much on account of the pain which they provoke as by
insufiicieticy of the muscles. I try to communicate movementa, and
I find that they have but little extent, and are stopped by an obstach
which cannot be overcome. It is very probable that this obstacle is
the painful rigidity of the articular and tendinous fibro-aynovial tis-
sues. This is already very marked in the radio-carpal articulation,
and is still more so in the phalangeal aod metacarpo- phalangeal articu-
lations. Pronation'and supination are also much hindered. In short,
this patient cannot use her hand for any of the ordinary purposes,
although it is evident that the muscles are not paralyzed.

Why this powerlessneas? How long will it last ? What can we
do to suppress or diminish it ?

I have already given the explanation. There has been arthritis of
the radio-carpal and inferior radio-ulnar articulations near the fracture.
This arthritis has passed to the chronic condition, leading to the re-
traction of the synovial membrane and of the surrounding fibrous
tissues, retraction which is the consec[uence of moat prolonged arthri-
tis when they do not take on the fungous form or white swelling.
The articulations of the fingers have tiecome inflamed and rigid, in
consequence of prolonged immobility. Two causes which did not
exist in the preceding patient have contributed in this one, not to the
development, but to the long duration of these arthrites ; the.'<e are her
advanced age, and the rheumatism from which she has been suffering
(or many years. ,

This union of disadvantageous conditions — the traumatism, immo-
bility, age, and rheumatism — makes me fear that the powerlessnesa
will last much longer than in the man. I advise the same treatment,
friction, massage, and sulphur baths. But I am not sure that they
will lead to a complete recovery. The movements will undoubtedly
recover a little of the extent which they have lost, but will never re-
cover it entirely, and there will always remain some pain. In a word,
the condition which you see, instead of being temporary as in the
other patient, will undoubtedly be permanent, and will constitute an
pIpSrmity.

1
I

PBACTUBBS OF THE LIMBfl,

LECTURE XXV.
FRACTURES OF THE LOWER EXTEEMITY OF THE RADIOS— Cohtinu^

I. Early phenomeDn and Eymptotua of reoeiit fraotura — Stndj of tlia mHohaDifl
Infleotion, tearing off, crnsliiiig, and penetratiou — Treatment — Iuimedia.tQ redae.
tiou— Best raining apparatus tliB flixtli day — RecasBily for gruat watclifulnesa if
it ia applied sooner. II. Immudiate reduction — Simple retention with Robert's
apparatus. III. Recent fracture in a. joung man 18 years old — Absence of
iialiing and penetration — I'robability of a oure iritlioat deformity and with
prompt return of tlie funotiona.

Gentlemen: We bave at this moment in our wards thrt
affected with recent fracture of tlie lower extremity of the radius.

I. The first is the one in whom the symptoms are the moat marked.
He is a man oS years old who slipped on the ice yesterday iiiorning
and fell. While falling he threw both hands forwards, and the
weight of his body was received principally upon the palm of his
right hand. No crack was heard, but sharp pain was immediately
felt in the corresponding wrist, and the patient, on looking at it, was
struck to find it sensibly deformed. He was not able to use it, and
saw at otice the necessity of coming to the hospital.

You notice the deformity of the wrist. It ia perfectly characteristic,
and is sufBcient in itself alone to establish the diagnosis. Without
going into many details, which would tell you less than the simple
sight of it, I call your attention only to three things: —

1st. An exaggerated projection backwards immediately above the
articulation of the wrist, witb a smaller projection upon the palmar
surface, below which is a slight depression corresponding to the promi-
nence on the dorsal surface; these promineoces and depressions to-
gether constituting what Velpeau called ialon de fourchelte}

2d. The level of the styloid processes. That of the radius instead
of having its point one-thirtl of an inch lower than that of the ulnar,
as in the normal condition, is exactly on the same level, that is, it
has been carried up the arm. This symptom, to which I attach
great value, was pointed out by Professor Laugier.

3d. If, while the wrist is flexed, you press upon the dorsal surface
of the forearm immediately above the prominence I mentioned, you
feel first the depression, and then in front of it, and deeper, a sort of
tense elastic cord, formed by the tendons of the radial muscles (exten-
i carpi radiales lyngior and brevior) which have been removed
from their normal position by the projection of the lower fragment
backwards. This sign also was indicated by Velpeau, who gave it
the name of the cord of the radials. ^

Silver-Cork fracture of the Eogliali i

rFRAOTURKS OF LOWER EXTREMITY OF RADIUS, 199iJ

Tha liand is very slightly inclined towards its ulnar border, and J
consequently baa not been drawn outwards, as occurs in certain f
exceptional cases which undoubtedly were seen quite often by J
Dupnytreo, and led this great surgeon to use a curvSd metallic ulnar I
splint, with external convexity, along which he bound the cubital 4
border oFthe hand so as to correct the deviation outwards.

r have made very little search for crepitation and mobility. The 1
patient suffered a great deal and I did not need these symptoms to 1
complete my diagnosis. The deformity was sufficient, for it could
not be explained otherwise than by a fracture of the lower extremity
of the radius, a lesion which offer.'; this clinical peculiarity that it can
be recognized in many cases by the deformity alone. There is, how-
ever, a circumstance which might lead us into error, I mean a contu-
sion or a sprain occurring in a wrist which remained deformed aftetj
I an old fracture of the radius. The patient would then present hin>S
• self to us with the characteristic deformity due to the anterior frao-^
ture, and in addition the pain and difficult movements caused by the
recent injury. It would then be quite natural to think of a recent
fracture. To avoid this error I questioned the patient. I asked him
if he had ever had his wrist broken, and it was after having received
an absolutely negative answer that I admitted without the slightest
hesitation the existence of a recent fracture.

Let us see, before going any further, 1st, by what mechanism the
fracture has been produced; 2d, the cause of tha characteristic de-
formity,

1st, As for the mechanism, I have to tell you that in this fracture,
as in most others, the information furnished by the questioning and _
examination of the patient does not solve the problem, J

We find indicated in our authors three principal modes according"*
to which the lower extremity of the radius may bo broken. ^

According to most of them, to speak only of contemporaneous
ones, the radius is caught, at the moment of a fall upon the p.ilm of
thehand, between two opposing forces, the resistance of the ground and
the weight of the body transmitted through the arm and forearm to
the ball of the hand. The lower extremity of the radius tends to
bend backwards under this double pressure. If the movement is
carried too far, it breaks, and the more easily if the cancellous tissue
has been rendered more fragile by the spontaneous rarefaction which
is the consequence of age, which arrives more or less early according
to the subjects, and indeed in certain persons is really premature. I
do not claim that this theory of inflection has been presented in an ■
absolute and exclusive manner, but it has at least been formulated.J
as one of the conditions of the mechanism in certain works and nota-J
blj in those of Foueher,' Am, Bonnet, and Philippeaux."

Others, and especially N^laton' and Voillemier,* insisted uponl
jiis circumstance, that in the fall upon the palm of the hand then

■ Fonclier, Balletin ie la Soo<a6 AnRtnmiiiiiH, lSfl2.
' Pbilippenux, BoMetin da Thgrnpeutique, ISSO, p. 2U7.
3 N^aton, EleuiHUts do Pathologie, touiu ler.
' Vollleuiier, lou. tit.

(

200 FHACTURGS OF THE LIMBS.

■Tadiua miglit be brobeo by the preaaure to whieb its cancellous tissue
is subjecte']. I regret that tbey did not use more explicitly the word
crushing, which would have maile the idea more eaaily comprehended.
But, if the word'is not at all or not sufficiently accentuated, the lact
certainly is, and it was the theory of crushing which led M. Voillemier
to study p^enetration which is only a consequence of crushing.

More recently M. 0. Lecomte, in a long and interesting work,' has
opposed the theory of crushing, which he makes the mistake of not
designating by its real name, and which he calls the theory of the direct
trarismission of the shock io the radius, and. developing a theory which
had already been advanced with reserve by Voillemier an<l Foucher,
maintains that in falls upon the palm of the hand the wrist draws
backwards and stretches the anterior ligaments of the radio carpal
articulation, that these ligaments exert traction upon the anterior por-
tion of the lower extremity and detach it by a mechanism which is
that of tearing,

'Here then are three theories — forced inflection, crushing, and tearing.
Which must we adopt for this patient ? Which must I advise you to
adopt for most cases? Neither one exclusively, and all three together,
with predominance of one or the other of them according to the age
of the subject.

For, as I told you a moment ago, the clinical documents do not
furnish any peremptory reason in favour of the intervention of one
of these' mechanisms rather than of another; and, on the other hand,
I do not feel disposed to apply to this patient, any more than to all
others, the results of experiments upon the cadaver. I know that
some surgeons, especially Ndlaton, Voillemier, and 0. Lecomte, have
tried to clear up the question by experiments of this kind. Bat
there are two conditions which cannot be reproduced upon the cadaver,
and which contribute greatly to the production of the lesion upon
the living subject.

The first is muscular contraction. I would not go so far as to
admit with Pouteau' fracture of the lower extremity by muscular
contraction, and especially by that of the long supinator, but I do
not the less admit that in a fall upon the palm of the hand, the con-
traction of all the muscles of the forearm, excited by emotion and the
instinctive desire to avoid danger, ought to draw the ball of the hand
upwards and increase the pressure of the bones of the carpus against
the articular facet of the radius, a pressure which favours crushing.

The second condition is this peculiar fragility induced by senile
rarefaction. It varies much according to the subjects, and it was not
noted if it existed or to what degree it existed in the cadavers used
for the experiments.

If, for these reasons, I cannot tell joii with absolute certainty what
took place in our patient at the moment of the accident, I can at least
offer you well-founded presumptions. Now, there is one condition
which exists in him as in most of those who have passed tbe age of

r FRACTURES OF LOWER EXTREMITY OF RADIUS. 201

fifty years, that is, the' rarefaction of the spongy tissue and tbe fra
gility which results from it. Notice that everybody falls, while walk
ing, upon the palra of the hand, that everybotly in ao simple a fall
does not break the radius, and that especially young people, aridfiduits
up to the age of 45 or 50 years, escape this injury. To be pro-
duced in them it needs a more energetic cause, aueh as a fall while
running or from a high place.

What is there then peculiar in old people that can explain this
lesion ? It is not the weight of the body nor the rapidity of the fall
which accounts for the easy production of the fracture. It ia and can
be nothing else than the fragility in question. Now this fragility is put
to the proof especially by the crushing, that is, by the pressure From
above downwards and from below upwards, to which the radius is
subjected in a very simple tall, and the intervention of this mechanism
has the advantage of explaining equally well the fractures after a fall
upon the palm and those upon the back of the hand. I admit that in
a fall upon the palm inflection backwards and tearing intervene to a
certain extent, and that the anterior portion of the solution of conti-
nuity may be produced principally by them, but the crushing of the
posterior portion is always the principal and even initial phenomenon.

I said that in the second place we had to explain the deformity. It
is the consequence of what we know of the mechanism. At the mo-
ment of the fall the lower fragment is forced backwards by the pres-
sure of the ball of the hand against it, undergoing, aa J'oucher
pointed out, a slight movement of rotation about its transverse axis.
Sometimes this movement is very slight, or when once produced it
corrects itself, and this is what explains fractures without deformity
or with a very slight one ; sometimes the fragment remains in its new
place, fixed there by muscular tonicity or by penetration, and then
the deformity persists, being remediable if the muscles are not too
energetic, or if the penetration is not accompanied by an insurmount-
able interlocking, and irremediable, on the contrary, if the opposite
conditions exist.

As to the prognosis, remember that we have not to deal here with
a serious disease; first, because life ia not at all endangered, and then
because in all probability consolidation will be soon obtained. In
general, 20 to 26 days of immobility and retention suffice. At the
end of this time, of coarse, the functions will not have recovered theii
integrity, and it will need considerable time for the articulations ol
the wrist and hand, as well as the neighbouring tendons, to recover
their motions and their normal suppleness. But the consolidation
will take place by a perfectly bony callus. The callus of course
would only remain fibrous in case the patient was still older.

The gravity of the aflection lies in the slowness of the return of
the functions, slowness of which I have already had occasion to speak,
and which will be all the greater here since the patient is nearly sixty
years old:

As for the treatment, I remind you of the precept which you often
bear me mention for fractures of the upper limb, that of not employ-
ing a restraining apparatus at first, and to wait until the inflammatory

202 FEACTDBE3 OF THE LIMBB,

period is over to envelop the limb and iaimobilize ihe fracture. I
applied flaxseed poultices sprinlilfld with lead-water or spirits of cam-
phor, am! told the patient to stay in bed. To be sure, he might be
allowed to get up, keeping his hand and forearm in a sling ; but the
movements would probably cause pain, and it is better to keep quiet.
Before applying the first poultice I made the manceuvre of redaction.
While one assistant held the upper part of the forearm firmly with
both hands, and even drew it slightly backwards, and another grasped
the patient's hand and drew it forward with a certain force, I embraced
the wrist with both hands and exerted the pressure necessary to press
the lower fragment forwards and the upper one backwards, and thus
correct the deformity. I did thus correct it, and you may have seen
that when we laid the arm down, the wrist had recovered its normal
shape. At first I hoped that this result would be maintained, as I
have seen on several occasions, and that then it would be useless to
have recourse afterwards to a restraining apparatus. But my hops
was not realized. In a few moments you saw the deformity reappear,
and you must have concluded, as I did, that if we wished to suppress
it definitively it was necessary to maintain, by means of a restraining
apparatus, the result obtained by the reduction.

Now for what reason did I decide to wait a few days before apply-
ing this restraining apparatus? Because in certain cases the appara-
tus, if applied immediately, is found to be too tight and causes pain,
eschars, and even complete gangrene of the hand and forearm. Do
not forget these two things; in fractures of the lower extremity of
the radius, as in all others, there ia, during the first five to eight days,
an inflammatory period, during which the limb swells. Then you
have here two quite superficial arteries, circulation through which ia
easily diminished or checked by the compression exerted by the ap-
paratus. If, then, you apply too tight a bandage, you may thereby
stop the circulation and cause the accidents I mentioned. If you
apply one which is not too tight at firat, it may happen that, inflam-
matory swelling of the forearm occurring, the apparatus may exert
at the end of twenty-four or forty-eight hours a constriction upon the
tumefied limb which it did not at the beginning, I am far from
wishing to exaggerate the danger. Certainly you may apply an ap-
paratus early if you are sure of not making it too tight, and especially
if you are able and willing to see the patient twice a day, and to
loosen or even remove the bandage in case pain or purple swelling of
the fingers warns you that the circulation is troubled.

Beware of the first of the symptoms, the pain. I know the lament
able history of a woman, 70 years old, whose surgeon applied the first
day a roller bandage for a fracture of the lower extremity of the right
radius. A distance of two leagues sepiirated the patient and the sur-
geon. It was agreed that the latter should be sent for if rather se-
vere pain should be felt, but that otherwise he should come only at
the end of sis days. The patient did not suffer, or suffered too little
to send for the surgeon, and when he arrived he found the hand and
forearm gangrenous. A very unpleasant litigation resulted.

It ia to avoid a complication of this kind that I advise you not t

B FBACTURE3 OF LOWEB EXTREMITY OF RADIUS. 203 ^|

^BUpply an early apparatus unless you are sure of being able to watch ^M
^p!t, and it is Btill better to apply only poultices during the first five or ^|

recommendations, which are good for all aubjecta,
are especially applicable to children, women, and old people, that is,
to all feeble subjects whose circulation is easily checked by compres-
sion of the radial and ulnar arteries. It is for those especially that I
recommend you not to place an apparatus upon the broken forearm
before the fifth day, whether it is a fracture of the extremities or of the
shaft. Yon may reserve, if you choose, immediate application for
vigorous adults, but always on condition of exercising a very close
%atch over it.

At the hospital you see that I reject in all cases the immediate use
of the constricting bandage, because, on the one hand, 1 wish to fix in
your minds the possible dangers of its use, and because, on the other
hand, this action does not affect disadvantageously the after-treatment
and the consequences of the injury. I see only one inconvenience in
it for the patient — that of being compelled to remain in bed ; for the
simple envelopment in a poultice does not sufficiently immobilize the
fracture, and exposes it to painful jars if the patient leaves his bed
and walks about.

The treatment for this patient will be as follows :-

Poultices sprinkled with spirits of camphor will be kept on for five .
days, and on the sixth I shall apply the restraining apparatus which
I have already described (see page 193), the one which I borrow from
Malgaigne, and by means of which pressure is made upon the dorsal
and palmar prominences. It is completed by graduated compresses
and splints kept in place by three strips of diachylon plaster four
feet long and two inches wide, so as to form what I call an open ap- .
paratus, by means of which the parts can be watched between thef '
pieces of the apparatus, and relieved by loosening the bands if it is '
found that, in spite of the late application, the constriction has be>'
come too great.

The bands will be removed at the end of a week, the forearm

IHiarefully examined, and a new attempt at reduction made if it i
tennd that the shape is not all that could be desired. The apparatus
bill then be reapplied as at first, and left in place until the twenty-
■rst day, counting from the time of the accident. I advise you never
B leave bandages for fracture of the lower extremity of the radius in
pace beyond this time ; first, because twenty-one days are sufficient
K) obtain consolidation, and then because a more prolonged immo-
bility would increase the painful stiffuess of the fingers which I have
pointed out as one of the consequences of the immobility caused by
apparatuses for fracture of the upper limb.

Finally, after the bandage shall have been removed, I shall pre-
scribe communicated movements, friction, massage, and sulphur baths,
BO as to shorten as much as possible the duration of the powerlessneaa
to which the patients are condemned for a longer or shorter time, ac-

trding to their age, in consequence of these fractures of the wrist.
II. The second patient of whom I have to speak interests you es-
cially from a therapeutical point of view.

)ed

ivo^^l

am 'I
il
s

204 FRAOTUKea op the lihbs.

H 20

^H He is 57 years old and has already been in our wards for a fort-
^H iiiglit. You remember that on the Brat day I made reduction as in
^H the preceding case. The attempt was sucee^aful, the characteristic
^H deformity ceased, and, diEFeriog iu this respect from the preceding one
^1 and from most of those ia which I make tlie same attempt, the result
^M was maintained, the displacement was not reproduced. Seeing that
^M the reduction persisted, I did not apply the open apparatus which I
^M habitually use, but contented myself with placing the forearm upon
^P a long bag filled with chaff and a splint, and fixing it with a roller
bandage. The cushion and the splint did not extend beyond the
wrist, BO that the hand was left free and flesed. This very simple
apparatus, which waa proposed by Robert, has the advantage of
neither compressing nor immobilizing the hand too much, and it also
diminishes the duration of the consecutive stiffness of the fingers, I
removed it this morning, and you saw that the shape of the wrist was
good, and that the functions, that is, the movements, although still
very imperfect, were much less limited than in patients upon whom
the ordinary restraining apparatus baa been left for twenty-one days.
I recommend this mode of treatment. It wilt not do for those pa-
tients in whom a first or second well-made reduction is not main-
tained. But it is excellent for those in whom the reduction main-
tains itself without retention. The immobility which it supplies is
suiEuient for the accomplishment of the consolidation, and it has the
great advantage of dimini.shing the duration of the painful stiftuess
and immobility which, aa you know, are the principal inconveniences
of fractures of the lower extremity of the radius.

III. The Inst patient of whom I have to apeak ia a young man 18
years old, who fell from a ladder, a distance of about ten feet, strik-
ing upon the palm of hia left hand.

We found upon him the first day the characteristic antero-posterior
deformity, without marked inclination of the hand towards the radial
or the ulnar side. In addition I easily felt mobility and crepitation,
and I was able at once to make reduction, which, however, did not
remain. Nothing in the way in which the accident was produced
enlightened us upon the mechanism of the fracture ; but in taking ac-
count of the age which authorizes us to believe in the existence of a
non-rarefied and still very solid cancellous tissue, and of'the facility
with which I was able to move the lower fragment and feel crepita-
tion, I think that the mechanism of (;rushing has not intervened,
that the cancellous tissue has not broken into multiple fragments as
is often the case in old people, that reciprocal penetration of the frag-
ments has not taken place, and that finally the lower fragment has
not split down to the radio-carpal articulation, as it does quite often
in people advanced in age.

From all of this I conclude that the regular shape obtained by re-
duction and by the restraining apparatus which I applied the sixth
day will be maintained, and tliat we shall not have consecutive de-
formity due to the disappearance, by absorption, of part of the can-
cellous tissue, as is sometimes observed after fractures by crushing
and penetration.

FBAOTCRE OF CLAVICLE BY MUSCULAR ACTION.

I hope, furthermore, that the arthritis by proximity will be leaa
(Tere anil of shorter duration, for this arthritis, which takes place in
almost all cases, is necessarily more marked in those it which the
fracture invadea the articular surfaces, than in those in which it does
Dot. Finally, this is a young man who has never had rheumatism,
and you remember that these conditions of age and health are favour-
able to the termination by resolution of traumatic arthritis.

I might have discussed the questiou of diagnosis, and asked if, in-
stead of a fracture, I should not consider this a tearing off of the epi-
physis. I do not think so, and for these reasons: the simple tearing
off of an epiphysis is rare, and when solution of continuity takes
place at the point occupied by an epiphysary cartilage, anatomical
observation has shown that it is produced almost always partly
upon the cartilage and partly upon the bone, so that a real fracture
coincides habitually with rupture of the cartilage. Moreover, an
epiphysary separation adds absolutely nothing to the results, nor,
consequently, to the prognosis or treatment. All the clinical interest
of the lesion, in such a case, lies in this peculiarity, that the spongy
tissue is solid, not rarefied ; that it must have escaped crushing, pene-
tration, and multiple fragmentation, and that finally the age predis-
poses to the prompt return of the suppleness and polish of the articular
and tendinous synovial membranes which have been consecutively J
inflamed. We have only reached the twelfth day, but I hope, if the
patient consents to come back and see us two or three weeks after he
leaves us, to be able to show you how much more rapid and indolent
the restoration of the movements has been than in the older patients.

205 ^M

3 less ^^M
ice in ^^B
1 thft ^*

LECTURE XX VT.

FRACTURE C

S CLAVICLE BY MU3CULAH ACTION.

DBldemtionB upon the mods of prodnotioi
fracture bj muscular action— The fracta
Bud witliout displacement, as iu ohililrei
ratas Inveuted for fracture of the claviol

of fracturea of thU bona — Case of &.1

i is vrithont rapture of the periostenia |

—Examination and critioiara of appa- I

-Preference girun to the aling — Sab- 1

Blitalion of the doahla sliug for Mayor's simple o

Gentlkmen: We have at this moment at No. 43, Ward Sainte- j
Vierge, a man, 40 years old, affected with fracture of the clavicle,'iQ'
whom this lesion was produced in an unusual manner.

You know that, strictly speaking, fractures of this bone may ha
occasioned by direct causes, such as a heavy body falling upon the I
clavicle, or a violent blow with a stick. But cases of this kind are J
much the least frequent, and in any case I have not observed the I
more or less serious concomitant lesions, generally called complicati'ons, j
which, in other bones, are produced by the vulnerant bodies which |
cause the direct fractures; I refer to considerable effusions of blood, j

208 PRACTDEE3 OF THE LIMBS.

phljctffinEB, eschars, and wounda. It is a remarkable fact tliat fractures
of the clavicle are very rarely compound, aod that the skin remnins
almost always intact, even wlien one of the fragments makes a very
pointed and apparently very threatening prominence under it. I
attribute this chiefly to the fact that direct causes rarely take part in
their production.

The most frequent fractures are those which are produced indi-
rectly by the action of causes which tend to increase the natural
curves of the bone, and to make it break at some point of one of these
curves, as when one falls upon his shoulder, or even the elbow, and
the clavicle is thus subjected to exaggerated pressure between the
sternum and the ground.

Another, which is observed quite rarely, is fracture caused exclu-
sively by muscular action. To this category belongs the one of which
I shall speak to-day.

On the 12th December, 1S68, this man was helping to place upon
the shoulder of a comrade a large, heavy piece of marble. At the
moment when he lifted it, he felt a slight crack in his right shoulder,
and was unable to continue. The next and the following days he
was not able to work as usual; nevertheless, he waited a week before
coming to the hospital.

As ne had received no blow upon the clavicle, and had not fallen
upon the shoulder, I did not think at first of a fracture, and I exam-
ined the deltoid region and the right acapulo-humeral articulation.
Not fiading any lesion at these points, I carried my eyes and then my
fingers towards the clavicle. I found at the middle of this bone a
round, quite uniform swelling. Then by pressing with one finger
upon this point, and gently moving the two ends of the clavicle in
opposite directions by seizing each one with one hand, I felt very dis-
tinctly a fine crepitation and abnormal mobility.

It is evident then that the clavicle was broken, and as there had
been intervention neither of a direct blow, nor of the usual indirect
cause, we are authorized to say that the fracture was produced by
muscular action ; that is to say, that the clavicle — drawn powerfully
upwards by the sterno-cleido-maatoideus and the trapezius when the
effort was made to lift the weight, and drawn downwards at the same
time by the contraction of the deltoid and pectoralis magnus, which
take their fixed point upon it to move the humerus — was ao forcibly
pulled in two different directions that it broke at the point where un-
doubtedly it was weakest.

It is true that if we consider the usual solidity of the bone we have
to doubt whether it could be overcome by muscular contraction, and
we ask ourselves whether the fracture had not been prepared in this
patient by a fragility due to an osteo- sarcoma, or to syphilis, or to the
peculiar osteitis which Malgaigne pointed out for other bouea, and
which must be placed in the category of rarefying osteites.

Now, the commemorativea were entirely opposed to the first opin-
ion, for the patient had not before the present accident any tumour
which could be considered as cancerous.

On the other hand, he has not had syphilis. And moreover, I^

FBACTUBE OF CLAVICLE BT MUSCULAR ACTION. 207

by no means convinced, as I liave already said when speaking of
spontaneous fracture of the femur, that constitutional sypnilis makes
the bones fragile, and for the moment I know of no fact wliich proves
that syphilitic osteitis sometimes takes on the rarefying form. Un-
doubtedly it is not impossible, but it has never been proved by ob-
servation, while, on the contrary, there is no lack of cases in which
syphilitic periostitis, called also periostosis, has terminated in a per-
manent increase of size, or hyperostosis, indicating the interventioa
of a condensing osteitis.

As for the special osteitis pointed out by Malgaigoe as preparing
the way for spontaneous fractures, we have no positive sign which
authoriiiea us to believe that it has existed in our patient. Rarefying
osteitis of the compact tissue, indeed, is only manifested to us by
physical signs, and the only functional symptom which might cause
it to be admitted is prolonged pain at that part of the limb where
rarefaction takes place. Aa our patient declares he has had no pain
of this kind, I cannot say that his fracture has had a rarefying osteitis
for predisposing cause.

Notice two things here: first, it may easily be that the slow and
prolonged osteitis which terminates hy rarefaction and fragility was
indolent. Second, it is not impossible, as I have already explained,
that the fragility may be due to a rarefaction independent of the in-
flammatory condition, rarefaction comparable to that which senility
leads to in the cancellous tissue of many long hones and which is pro-
duced without pain. I there touch upon a question which has been
but little studied. Our anatomo- pathological studies have made ua
acquainted with senile rarefaction of the cancellous tissue; but they
have produced nothing yet for the analogous trouble of nutrition of
which the compact tissue becomes the seat as age increases, and even
without senility, or without the influence of a sort of premature seni-
lity- I should like to have this question studied ; it might enable ua
understand better than we can to-day the facility with which direct
indirect causes produce fracture of the most voluminous bones,
such as the tibia, the patella. I have long asked myself whether, in
such cases, premature senile rarefaction has not induced a fragility
which has facilitated the production of the fracture by chance causes
apparently quite slight, and it is a subject which I recommend to
your investigations.

But it is not only with respect to its etiology that our fracture is
an unusual one ; it is so by its physical symptoms also.

I said that I had found a little mobility and fine crepitation ; but I
id not speak of a projection upwards of the inner fragment, nor of a
wer prominence formed by the end of the outer fragment pulled
iwnwarda and pressed under the other. In other words, I have
it spoken of the prominences and deformities which are most fre-
lently found in fractures of the clavicle in adults. Why? Be-
lae these prominences and this deformity do not exist here. We
only a round tumour, rather voluminous, but regular and without
ualities. The fracture then is without displacement, and with a
.ume which is explained by the fact that it is a week old ; that

FHACTDBKS OF THE LIMB

during this time the patient has not been treated, and allhongh be
has not been working he has continued to use his arm.

Why this absence of displacement? Because there has been no
rupture of the periosteum, or because the fracture ia toothed, and
the points have remained interlocked, and the periosteum has thick-
ened, as it does in our experiments upon animals when the fracture
has been without displacement, and the fragments have been kept end
to end.

This variety is rare in adults, but much more common in children,
where it merits special attention on account of the diEBculty of the
diagnosis. I show you from time to time at the hospital consultation
children four, five, or six years old who are brought to us for fracture of
the clavicle without rupture of the periosteum, the principal symptom
of which is a swelling, painful on pressure, at some point of the bone.
Immobilization with a sling for a fortnight is sufficient to reduce the
volume of the tumour and to have it replaced by a solid and scarcely
visible callus.

You saw me employ for this patient the treatment which I use for
almost all cases of fracture of the clavicle. It is a allng similar to
that of Mayor, but which, instead of being a single triangle, is a
double one, or, if you prefer, a piece of cloth, such as a handkerchief,
folded so as to form a triangle with two thicknesses. The forearm
ia placed in the fold formed by these two flaps. The extremities of
the base of the double triangle are attached to one another behind the
back ; the point of the posterior flap passes in front of the uninjured
shoulder, that of the anterior flap in front of the injured one, and they
ace fixed to the ends of a compress looped around the posterior and
horizontal part of the sling, which ends pass over the shoulders to
meet the two points to which they are then pinned or aewed.

This simple bandage has no other object than to keep the shoulder
and the clavicle immovable, and to thus favor the consolidation. In
the present patient there is no other indication to be met. But in
those cases where there is displacement of the fragments, you see me
use the same aling. I only add, when the inner fragment projects
forcibly upwards, compression on it by means of a layer of cotton
and two compresses placed under the junction of the anterior point
of the sling and the compress to which it ia fastened.

I do not mean to say that this simple apparatus always gives per-
fect results, that is, cure without deformity. For fractures of the
clavicle are like thoae of the leg. Some are without displacement,
like this one and like those which we often see in children, and then
the most simple apparatus is sufficient if it immobilizes. Others have
a displacement which it is easy to reduce and to keep reduced. The
simple apparatus does very well for these also. Others, finally, are
reducible, but very difficult to maintain, because the displacement
is reprmluced by the slightest movement. In such cases I claim,
and it is the opinion already expressed by M, N^lalon,' that a simple,
well applied sling gives as good results as auy of the more or less
complicated apparatuses proposed at different times.

iU^toD, El^euta dd PatliologiH Dhirargicalti, tome Iv,.

FBACTURK OF CLAVICLE BY MU3CULAR ACTION. 20W

it In fact, if we study these apparatuses, we see that the principal ob»]
J8ct of most of them is to meet a proper indication. A great numbar^
for example, from the time of Hippocrates to the end of the eighteentl '
century, are intended to carry upwards and backwards the oiite:
fragment which is lowered and carried forward. Suoh especially wai
the object of those described in the works on surgery under ihc name
of Ileister'e cross, Brasdor's corset, and Bninninghausen's strap.

At the end of the last century Dcsault showed that it was necessary
to carry the outer fragment not only upwards and backwards, but
also and especially outwards. For that purpose he proposed the ax-
illary arrow-head eashion, intended to carry the humerus, and with it
the scapula and clavicle, outwards, while a figure-of-8 bandage passed
around the elbow of the injured side and the opposite axilhi, and
crossed over the broken clavicle, and held the shoulder and outer frag-
ment up and back. Boyer's corset was also constructed to meet then
aume triple indication.

All these apparatuses, one after the other, have had to underg*
about the same criticisms,

Desault justly reproached all that had preceded his with not meet-i
ing all the indications, with troubling the patients, and often giving
care with prominence of the inner fragment.

Boyer objected to Desaull's bandage because its hard cuahioa
caused pain, because it interfered with respiration, and after all did
not always prevent displacement of the fragments.

Boyer's apparatus is open to exactly the same objections, and when
Mayor, of Lausanne, in 1H34, proposed to suppress the arrow-head
cushion and the complicated bands, and to substitute for them a sim-
ple sling which would carry the elbow inwards and upwards, and
consequently the shoulder and the outer fragment of the clavicle out-
wards and upwards, he had no difficulty in showing that this bandage,
reduced to its most simple expression, gave results not inferior to
tho.sie of the complicated apparatuses previou.sly used.

I have modified Mayor's sling by making it double instead of single,

KDd thus fixing it more solidly. But I add that the main indication
'hich it meets is that of keeping the clavicleandahoulder immovable.
Before applying it I make as complete reduction as possible by the
uianoeuvre which consists in carrying the elbow inwards and upwards
■with one hand, while with the other, placed at the inner and upper
part of the arm, I draw the ahoulder further outwards. That having
been done, I press the upper fragment downwards, and while the re
doction is made I apply the sling as before described; on the follow^
ing day I raise the anterior point of the sling and renew, if it has be-
come relaxed, the pressure exerted upon the upper fragment by the
compresses. But I do not believe, like all of my predecessors and
Bome of my contemporaries, that I can maintain reduction of all frac-
tures with displacement. I maintain some of them, but there are
many which are maintained only very imperfectly, and which recover
with a slight deformity and shortening. But as the objections made
successively to all the methods of treatment prove, to my mind, that
these defective results were inevitable and depended upon the uoadi-

it
!d

f-M

i ^

I
)

210

FBACTURKS DP TBK LIMBS,

tions of the fracture, I acuept them as suuli, and do not claim t<( he
able to avoid tbem. These irregular calluses, moreover, cause very
little inconvenience; on the one hand, they do not interfere in any
way with the functions of the limb, and on the other hand, they di-
minish with time because the point of the upper fragment is absorbed
little by little. That which remains would be disagreeable only la
ease the patient were a young ladyand compelled to appear in society
with bare shoulders.

To avoid criticism, and to protect his responsibility, the surgeon
should, in such a case, give the preference to Desault's bandage, the
application of which, becanae it requires minute care, excuses the im-
perfection of the result. Indeed he might, in imitation of the fact
eited by Mayor,' propnse manual retention, that is, retention with one
hand left permanently upon the fracture, as the only means of cer-
tainly obtaining a cure without deformity.

, I have a last remark to make upon the treatment of fractures of
the clavicle. It is not necessary to leave this bone immovable for a
long lime; twenty to twenty-five days are Bufticient for an adult,
fifteen to twenty days for a child.

At the end of this time it is necessary to examine carefully the
condition of the bone, and allow movement if mobility and crepita-
tion are no longer found. In those cases where the functions of the
limb are slow to become re established, it is due most often to this,
that, the apparatus having been kept on too long, the articulations, and
especially the small ones of the hand, have taken on, in consequence
of the immobility, a greater rigidity than they would otherwise have'
done.

' Major, Chimrgie fjimpHSee, touiti ii.

PART III.

TRAUMATIC OSTEITIS AND NECROSIS.

LECTURE XXVII.

TRAUMATIC OSTEITia OF LONG B0NE9.

i Sxpose<l wounds oF the
rul&tioiia witb s^ptici
mi Oil oliaracteriBtiua-

cute OS tno -my el it [9, aapporaling, anS pnlri
lamntic fHrar and purulrnt inreattDD) — Its antito-
aidence with Hiaiple pliUbitis and patrid plilebitil.

Gestlemen: I gladly take the opportunity which is offered to-
day to show you the pieces coming from three patients who have
aucuurabed, one of them to traumatic fever, the other two to purulent
infection, after injuries which had placed the boiiea in contact with

t'the air and had exposed them to suppurating traumatic osteitis.
c' T shall speak to you on some other occasion' of the relation which
"exists between acute suppurating oateitis and these two dangerous
I'disesBea which it often engenders: traumatic fever and purulent in-
/■fection or pyaemia.
^ To day I leave the latter aside to call your attention solely to the
first, the osteitis, which you will not find described in our classical
authors with all the details which it deserves.

I. Notice first these two tibias : they belong to that one of our _
lients who was admitted six days ago for fracture of the middle poi
lion of the right leg complicated by a quite large contused wound.
The skin was not gangrenous, the wound was covered with blood
clots, exudations, and small superficial eschars, which are seldom lack-
ing in the first period, that during which suppuration of the contused
wound is preparing. At the same time an abundant and fetid liquid
escaped from the superficial and deep layers. Twenty-four hours
after the admission of the patient a burning fever came on, with 125
to 140 pulsations, the temperature rising to 105° in the evening, and
varying between 103° and 104° in the morning. Then, after two
days, delirium set in, so that the patient had to be tied in hia bed ;
ihen the abdomen swelled, and at the end of six days, during which
I the leg had notably increased in size, and the wound had not ceasi
Kto furnish an abundant and reddish fetid discharge of which I shajl
rspealc in a moment, death occurred.

The fever was not preceded by a chill.

cal ^^

212 TRAUMATIC OSTEITIS AND NECROSIS.

At llie autopsy we found none of the visceral lesions of purulent
infection. Furthermore, we found no appreciable lesion, either of the
brain, or of the throax or abdomen. The only thing which attracted
our attention was the enlargement and friability of the spleen, and
the aanie distension of the intestines which we bad remarked during
the last days of the patient's life. It is evident, then, that the patient
has succumbed to one of these febrile affections without appreciable
lesion, upon which we can discuss for a long time without eoniing to
a conclusion, or at least without convincing those who demand visi-
ble, materia] demonstrations in support of the explanation of the
death. Without spending any time in this discussion I shall content
myself with telling you that in my opinion, according to the negative
results of the autopsy, the patient succumbed to what we have called,
since Dupuytren,' intense trav malic fever, and to what we can consider
as one of the varieties of traumatic septiciumia, that is, acute aud pri-
mitive septicemia.

But let US return to the examination of the bones. This is the
tibia of the uninjured side. Externally it shows nothing peculiar.
But I have broken it with a hammer to see the inside; you there
find the medullary substance of the shaft and that of the cancellous
tissue of the extremities with its reddish-yellow colour. Its injection
is more marked than in many subjects, and might be considered
hypersemic. Bui you must remember that nothing varies in dif-
ferent subjects so much aa do the proportions of the vascular and
fatty parts of the marrow of the bones. Here, the vascular element is
greatly developed; but you find nevertiieless the yellow colour of
the fat which crushes easily under the finger, but is not fluid ; whea
rubbed upon paper, aa I rub it now, it leaves large greasy spots. lis
appearance is the same throughout; you find in it no effusions of
blood, no plastic deposits, and, above all, you do not find the fetid
odour which recalls that of putrefaction or maceration of the bones.

Compare this with the other tibia, the one which has been broken,
and broken by an indirect cause (the patient had fallen while running,
and the upper fragment had pierced the skin). Between tlie two
principal fragmeita, for the fracture is slightly comminuted, you see
softened blood clots which break under the fingers and give a very
fetid odour; in the medullary canal of these fragr.-ients you find a
substance which is much darker than that of the opposite side, ia
softer, and, above all, has a fetid odour. This substance shows ia
only a few small places the yellow colour of fat, and it greases the
paper much less. At two points you find whitish deposits which are
also fetid, and are composed of infiammatory products. These lesions
extend about an inch beyond the solution of continuity, and on the
upper fnigment are continued aa far as the cancellous tissue of the
extremity.

If you saw the marrow of this side alone you might fail, as
happened to many of our predeceaaora, to appreciate what 1 consider
the very considerable morbid conditiuu which exists. But if you

tTRAUMATlU OSTEITIS OP LONG BONKS. 213 ^H

lotice the diPTereoces betweea it and the opposite side, you see that^^f
his medullary substance is profoundly altered, and that its alteratioo^^^^
consist especially in the intimate combination of the fat and tha^^H
albuminoid substance with blood poured out by the torn vessels, a. ^H
disappearance, either by absorption or by esca|)e to the outside, of ^H
a part of thia fat, and finally a putrid decomposition, as well of the ^H

b«

^.hft

Fth>

_.oad

part of thia fat, and finally a putrid decomposition, as well of the
nflltrated blood as of the marrow itself and tlie exudated products,
lething has taken place here which is analogous to that wliich
'occurs in a wound of the soft parts, and which always takes place
m the first period of contused wounds which are preparing to sup-
purate. Tbe tissues exposed to the air by the accident inflame,
become partly gangrenous and putrid. But here the putrefaotion
.has attacked the fatty parts at the same time with the blood inclosed
an almost incompressiSle cavity, into which the air penetrated
.sily as soon ps a part of the liquid contents escaped. Notice, on
the one hand, that thia putridity has invaded that one of the fatty
of the body which is normally the best protected and most
hidden, and which, for this reason perhaps, supports leas easily thaa
any other the consequences of exposure to the air.

Even if it should not be admitted that this lesion has the gravity
hich I attribute to it in considering it the starting-point of the
trid absorption which causes the septicemia, you will admit that
lis decomposition of fat and blood at the bottom of a bony cavity
ight to be mentioned.

Our predecessors paid no attention to it, and the modern writers
ho have the merit of having attached their names to the description
osteo- myelitis, eapeeially Raynaud,' Chassaij^nae,^ Th. VuUette,*
id Jnlea Roux,* omitted to describe the first period of this osteo-
lyelitis.

They spoke especially of the period of suppuration. Tt is true
that they said that before the suppuration there was hyperaJTiiia with
exudations, but they did not describe this form, at the same time
exudative and putrid, which is not yet gangrene, but is very near '
and is even sometimes gangrene in places. It is the possible but not
inevitable consequence of compound fractures, and I considei
one of the forms of osteo- myelitis. I call it putrid osteo m'jelUk pr&-,
ceding suppuration, or primitive. Taking into account the propagi
of the medullitis along the medullary canal, I might even call it
',nd and dijfuse oateo-myelilia.

I looked to see if the neighbouring veins were affected. I could find
nothing in the nutritive vein at its point of emergence from the nutri-
tive foramen. But the posterior tibial and the popliteal veins were
obliterated by clots, without admixture of serosity or of pus, ami
ithout tbe fluidity and the bad odour of coagulated blood. I did not

Kaynaad ; De rinflamniBitioii da Ti^ii mMnllalre del Oi Inngg (Archire
Jea da M£dH<nue, IB31, loms iitI. p. Itll).
~ Cli&ss&ignao : M^tnoire snr rO^tSo-mySlite (Gnzotte Uf^lloAle, 1S54).

Th. Vallatte; Oaiette ites HOpiUax, 185B. p. t"*

J, Roiix ; De I'OatSo-mySlite «t Ana Ampatntioi
ha. (M£m. d« TAaad. du M^dauine, IblJO, tom<

I
I

214 TRAUMATIC 0STBIT18 AND NB0HO8IB,

find the internal membrana of the vein thickened, and I cannot aaj
that thia vein was actually inflamed; I might llieii use the torm
Bpontaneous coagulation or thrombosis, accompanying putrid osleo-
inyelilifi. I shall often have occasion to point out to you the frequeocf
of the ooincidence of these venous lesions with osteo- myelitis, and to
discuss the nature of the first. To-day, I content myself with telling
you that if it is allowable to doubt, in this and in similar oases, the
reality of the inflammation of the surfnee of the vein, there are, on
the other hand, reasons to admit this inflammation ; and, aa the blood
contained in the veins thus affected presents capital differences, acoord-
ing to whethaj" it has retained or lost its chemical qualities by decom-
position, according also to whether it alone fills the vein or is mixed
with pus, which can be attributed to nothing else than a phlebitis,
I continue to admit phlebitis in cases of this kind. I only say that
here the phlebitis is coagulating and not putrid.

II, Examine now this upper half of n right femur.

It comes from a patient 32 years old, whose thigh I amputated
eighteen days ago, for a white swelling of the knee. He was carried
oft' by a purulent infection, of which the first chill occurred on the
tenth day, and which bad been preceded by an intense traumatic
fever.

You know that we found metastatic abscesses in both lungs, bnt
to-day I wish you to study especially the lesions of this femur.

You notice, first, that the periosteum has entirely disappeared for a
distance of about an inch. What has become of it? Has it been
destroyed by gangrene? Has it been absorbed? It is very difficult
to give a satisfactory answer to these questions, because we do not
see the succession of the phenomena upon the living patient. Wo
perform an operation ; we leave the bone covered by the soft parts;
and iva carefully avoid raising the latter evory day to see what is
taking place upon the former. And, when we have the opportunity
to examine it, either during life or after death, we no longer find the
periosteal covering, and we cannot know how it disappeared; but
remember that Reynaud' has pointed out the remarkable peculiarity
that, in such cases, the marrow inflames and suppurates to a height
which is about the same as that of the destruction of the periosteum,

We have broken the femur and found the marrow altered a little
higher than the periosteum. The alteration consists, as you see, in a
diminution of volume, which has left a gap and, consequently, a
place for the air; a grayish putrilaginous softening; and an absolute
impossibility to discover the normal anatomical characteristics of the
medullary substance; here and there very fluid pus; but above all,
a fetid odour, aa well of the putrilaginous as of the liquid part. I look
to see if the Haversian canaliculi also include this broken-down
matter and fetid pus; it is not very certain, but that is undoubtedly
due to the amallness of the parts; for, by using a glass, I can see in
the smiill open cavity of the canaliculi, a grayish liquid which loolta
like serous pus; and I do not find the reddish colour which india '^~

TBAUMATIO OSTEITIS OF LONG BONES.

2ie<

the presence of bloodvessels. Moat of these vessels seem to hav^J
disappeared, and, as the difi'ereiit sections of the compact tissue ar«
less red than those of the other femur, I coiiclLide that this one,l
although alill living, had nevertheleaa lost a part of its meana ofjl
nutrition, and, enlling to mind those patients who, after suppuratiooJ
of the bone, have had consecutive necrosis, I find here the first perio4»B
>f a necrosis which would inevitably have taken place if the fatal, |
lyaamia had not intervened.

The chief point in this specimen is the profound alteration of tha»^
marrow, its traasformation into dirty broken-down matter, and its r
fetid suppuration ; lesions which are doubtless due, in part, to the«
nature of the inflammation, and mainly to the decomposing inSuenc&t'
upon this inflamed marrow of the outer air within the gaping eavitv
of the medullary canal; and, as the walls of the Haversian canalieuli
are also rigid and gaping, I find in it another reason for believing
that piitrid suppuration in them coincides with that which takes
place in the central canal.

However that may be, I see there the second degree of the diseasQfl
of which I showed you the first degree upon the preceding speoimeriii
It is still a putrid osteo-myelitis, but the putridity no longer aft'ectsj
the infiltrated and cQ'used blood; it is that of the pus and of th&r|
remains of the profoundly altered marrow. It is, in a word, consecu--.
tive putrid osteo-myelitis, or, if you prefer, putrid suppurative osteo-n
myelitis. i

Remember this fact and its coincidence with purulent infection, il
for, when I shall discuss the pathogeny of the latter in your pre.sence,,.|
I shall refer to it in support of the opiuion whioh I shall then express.J

A final remark : the crural vein, which I here show you, is filled^]
with softened clots, and here and there contains fetid pus. Its ia-<
ternal membrane is slightly thickened and friable ; its cellular coat 1

also thiekened. These are certainly the anatomical characteri^tiua'il
if phlebiiis, and since the matter contained in the vessel has under- J
Vone putrid decomposition, like that of the marrow, I conclude ihatiij
this is a putrid phlebitis. I look in vain for direct vascular com-j
manication between the marrow and the crural vein. On the
hand, the amputation having been made above the nutritive foramen,^]
I cannot find the nutritive vein, the only one large enough to be™
easily dissected out. On the other hand, the other veins, which (^
might perhaps have established the communication, are too small to.^V
he perceived, and many of them have doubtless disappeared in cou-
iwquence of the beginning of the mortification of which the marrow
iHd the compact substance itself were the seat.

You see that I am again, as I was a moment ago, struck with the-*

iocideuce of the osteo-myelitis and the phlebitis ; I am preoccupied

th the possibility of a pathogenic relation between them ; I should
_ike to know if the suppurative phlebitis is developeil independently,
Xir if it owes its origin to the passage into the veins of putrid matter
coming from the marrow through the veinules leading from the J
bones. But I have no proof, and can only insist upon the coiiici- '
deuce of the putrid phlebiiiii with the putrid osteo myelitis.

TRAUMATIC OSTBITIS AND NECBOSia.

I do not claim that these two things always coexigt. I showed
you, a moment ago, a primitive putrid osteo- myelitis with a non-
putrid phlehitis. I shall show you, in other cases, putrid suppurative
osteo- myelitis without any apparent phlebitis. The coincidence is
ueverthelesa very frequent, and might to be considered when the
mode of development of purulent infection is discussed.

Ill, The third piece is the skullcap of a patient in whom we
recognized the existence of a fracture of the parietal bone, together
with a contused wound of the right side of the head.

Suppurative inflammation had invaded both the external wound
and the bone, the parietal bone became denuded by one of those
rapid disappearances of the periosteum which occur in acute suppu-
rating osteitis, and the mechanism of which is not yet well known.
On the ISth day chilU commenced, then followed the cortege of the
symptoms of purulent infection, and the patient died on the twenty-
second day after the accident.

You know how frequent this kind of death is after compound frac-
tures of the top of the skull. Yon will read of cases of abscess of
the liver occurring after wounds of this kind, and the insufficient
theories oftered in explanation by J. L. Petit, Bertrandi, Quesnay.*
Your books will show you that afterwards, according to the valuable
works of Dance* upon suppurative phlebitis, and those of Breschet*
upon the large venous canals of the diploe, the opinion was produced
that the abscesses of the liver are the consequence of a consecutive
infection or mixture of the blood with pus formed in the large bony
veins of which I have just spoken. The latter become inflamed and
suppurate, as do those of the soft parts, and allow a part of the ptia,
which is formed by the phlebitis in their interior, to enter into the
circulation.

In this specimen you recognize the exactitude of the fact. One of
the fragments into which I broke the bone with a hammer shows us
an open vein of the diploe. This vein contains serous pus. Un-
doubtedly here was a suppurative phlebitis. Moreover we followed
a veinule leading from the inner surface of the skull to the superior
longitudinal sinus. This veinule and the sinus itself inclosed clots
without apparent pus, so that We have a suppurative phlebitis of the
diploe with a non-snppuratlve and simply adhesive phlebitis of the
veins ex;ternal to the bone. But I beg you to again notice hero, two
anatomo-physiological cbaraoterisiics which escaped the attentiou of
our predecessors. B'irst, this pus which is in the vein ol^ the diploS
is serous, of a bad aspect and fetid odour. Secondly, it is not the
vein alone which is suppurating; it is the entire diploe of the parietal
bone. It is true that you do not see the pus ilow; it is not abundant
enough for that. But look more closely at this diploe, and compare
it with that of the other parietal which I have also broken. The

M^moirrt Bt prix do I'AcddemiB ds Cliimrgie, Par

s, 1747-1797.

Dance, Sar la Phlfibilu BXtErue at la Plillililte an g

HBral. (Arclii»aadeM6deo[n>,

BreSi;LHt, ReeliBrfhei AiiiilomiiinBS, Phyz-iologiiiiio

3 Ht PathotogiiiiiBs, Bar Ib 9jb.

VBineux, Piiri*, 1837-aa, in toUo.

NKCB0S18 OF THE LONG BONES,

Solour is not the same; it is a dirty-gray in tlie first, and pink in the'
second. Nor are the contents of the cells the same; yellowish in
many points, and bluekish in others in the first, where it is coi
of pua mixed here and there with blood ; it ia more purely red in the
second, w'here it ia composed of blood and fiit. Nor is the odour the
same. That of the first comes much nearer putrefaction than does
that of the second. In short, here too ia suppuration not only of the
bony vein but of the whole diploe, and as the contents of the diploS'
are really analogous, in the normal state, to those of the medullary
canal and of all the cavities of the long bones, I consider this also an*
acute suppurative osteo-myeliiis; and on the other hand, as the pus/
is of had quality and putrid, and as a fatal infection followed the>
diploic suppuration, I consider that this suppurative osteo- myelitis ia»
putrid, and, for reasons which I shall hereafter give you, I place in '
this serious lesion the origiu of the purulent infection which carriod'
oB' the patient.

n the'^^l

LECTURE XXVITT.

NECROSIS OF THE L0N9 BONES.

Its origio is most often traun

kObsdurityuf former dtiKO.
ia a rvenll of supparatiT
paniaB it — Accnunt of a

Opetation— PeiBisteiice of a long us

ntivin adults, spontaTieoua in chili^rHn B.iirl adoleiicf
iptious — Too ready bcliaf in a period of repair — Nb
1 coiidensiug ostwilis, like tha liyperoatosia wliioU acoom-Jj
HiCti InTagiualud aequestram— ^

Gentlemen; I have often had occasion to show you patients upoa
whose limbs were fistulEQ with longer or shorter suppurating tracts,
which ended at denuded portions of the long bones, some of which. .
portions were still immovable, others movable and about to be ex-
pelled. You have not forgotten, especially, the femurs, tibiaa, and, ■
humeruses which had been broken by balls, and which, after having M
been attacked by general suppurative osteitis, lost at different times
mortified fragments, which we called splinlers when they were small,
sequestra when they were rather large. Nor have you forgotten those
adolescents in whom I showed you the elimination of similar splin-
ters and sequestra after sponlaneoua epiphysary osteitis. Finally,
you know that we gave the name necrosis to the condition of mortified
parts of the skeleton which are destined to be expelled. But you
nnderstood and have remembered thai necrosis is an incident super-
added to suppurating osteitis, when the latter is not putrid and faial,
and especially to general suppurating osteitis, that which occupies at
the same time the periosteum, the parenchyma, and the deep parts of
the bone, that is, the medullary canal, and the whole thickness of the
cancellous tissue, when it ia the extremity that is affected. Our
authors, in describing necrosis, made a mistake m iaolatintf this deep

218 TRADMATIC 03TBIT18 AND NECEOSIS.

Bupporaiive osteitis, or osteo-mjelitia, and making of it a special*
pathological entity. That is true and proper for the very thin flat
bones, Buch as those of the palatal amh, and the turbinated bones.
For them the phenomena of the auppuratiDg osteitis are so alight, anil
the consequences of the loss of substance of the bone, whic.'h, more-
over, are generally inseparable, are so predominant, that I understand
the importance given to the phenomena mortification and elimiaatioD
by a description which is confined almost exclusively to the necrosis.

But you may have noticed in the shaft of the long bones, in the
cases of which I have juat reminded you, that a great analomo-
physiological and clinical phenomenon, non-putrid suppurating oateilia,
precedes the neurosis, and that another phenomenon, hyperostosis,
accompanies and follows it. The necrosis consequently is a conseco-
tive lesion, and, as it were, superadded to two others, suppuration and
hypertrophy; and it belongs to a variety of osteitis whioh, to be
well characterized, ought to be called contknsing and neci'otie suppu,-
rating osttitis. This connection of course is not sufficient for ua to
give up absolutely the description of necrosis. On the contrary, I
consider this description necessary for those cases in which the disease
has reached a period at which, the suppuration and hypertrophy no
longer having any gravity or clinical interest, the mortification and
elimination constitute the morbid condition, and alone call for the
attention and intervention of the surgeon. But this too ready belief
in the entity necrosis is based upon a physiological error which has
greatly obscured the descriptions, and which it is time to correct,
This error consisted in subordinating all the phenomena of the dis-
ease to a reparatory effort preceded by a destructive one. Bead the
works of Troja, Weidmano, Eoyer, and all the contemporaneous
French treatises upon this subject, you will see that their main object
is to show how the bone is renewed, and to present its excess of volume
as the result of a reparatory process supposed to be produced some-
times by the periosteum, sometimes by the marrow.

This opinion was based upon experiments made by Tnija and
Weidmano, experiments which consisted in destroying the periosteum,
the marrow, or the nutritive artery of an animal's tibia, and noticing
the anatomical phenomena whicli followed those lesions, These
authors found that, after a certain length of time, the central part of
the bone, which had been deprived of its nutritive materials, became
mortified and surrounded by a bone which they supposed to be new,
and to have been furnished by the uninjured periosteum. But to
protect this interpretation from criticism, the destruction of the
marrow should have been followed by the mortification of the whole
thickness of the bone in those animals in which they fonud ceutral
necrosis. Now, this has not been observed, and it is very possible
that a part of the thickness nourished by the periostea! and muscular
vessels may have escaped the destruction, and that the new bone may
have been furnished by this portion of preserved bone, and not by the
periosteum. On the other hand, in the experiments in which they
destroyed the periosteum, the mortification did not necessarily extend
to the marrow, aud tliey were nut uuthotized to say thAt iu such casw

■ NECROSIS OF THB LONG DONEa. 219i

it was this organ that had produced the new bone; for, as in the other;
case, it might faave come from the part of the bone which remained'
alive.

I have never understood why they have so readily and so generally
admitted the reproduction of the bonea, either by a pretended medul-
lary membrane, the non-existence of which I long ago demonstrated,
or by the periosteum, and why they have had so much difEculty to
admit that the bone itself, by its compact as well aa by its cancelloua
tissue, should be able to grow, to vegetate, to produce, in a word, new
oasifieation. In my opinion, it is sufficient to observe the clinical
course of osteites, and a few specimens of pathological anatomy, io
order to be convinced of two things: lat. That bones can complete
and repair themselves after spontaneous lesions, as I told you took
place after fractnree, by an augmentation of the nutritive movement
in their frame itself, as well aa by the hyperactivity of their envelope;
2d. That, moreover, in osteitis in man things take place dilierently
than in experiments upon animals, and that observation of the facta,
far from showing a period of repair consecutive to a period of elimi-
nation, tended rather to show that destruction was a salutary effort
f) rid of aiiperfluouB matter the bone, which had become too volumi-
ous aa a result of the hypertrophy and the osteitis which produced it.
To convince you of the correctness of these ideas, let me remind
ou of two pieces which T had occasion to show you last year, and
which had been taken from two patients who had had for a long lime
before their death, the one a spontaneous osteitis of the femur, the
other an osteitis consecutive to a fracture and the formation of a callus.
[ insisted upon the capital fact that, in one as in the other, there had
' sen no bony suppuration. The osteitis had remained plastic, to aae

a expression which I have often employed; the periosteum and the
medullary organ had been neither thinned nor hypertrophied. But
[ showed you in the sawn bone a compact tissue twice as thick aa in
pe normal condition, and much more dense, and a cancellous tissue

irith smaller ceils and stouter trabecuhe than usual. An excess of
Dony substance had evidently formed, and had increased the volume
aad the weight of the bone, and the object of this excess had not
been to repair a loss of substance, for none had taken place. It waa
a simple product of the disease, that is, of the osteitis, and I showed
you how just and useful was the expression of condensing osteitis
invented by Gerdy. But in the casea of which I speak, the condensing
oateiiis had taken place without suppuration, it had been the plastic
condensing osteitis.

Let us now return to the traumatic suppurating osteitis of adults,
to the acute apontaneoua suppurating osteitis of adolescents. What
bas the clinical and an atomo- pathological study of them shown ua?
The clinical study has shown us lour things in the succession of
observable phenomena.

lat. The destruction of the periosteum to a certain extent,
fc 2d. Suppuration invading the surface, the whole thickness, and the
^bedullary canal of the bone, taking, in short, the extension which it

220 TRAUMATIC OSTEITIS AND NECROSIS.

has in the acute suppurating eateo-myelitis of adolescents, and accom-
panied, furthermore, by similar febrile phenomena.

Sd. The increase of volume, quite similar to that which we found
in the simple plastic and condensing osteitis.

dth. Afterwards, and long after this hypertrophy, an elimination of
the necrosed portione, a single elimination in some patients, and a
repeated one in others, with numerous variations in the volume of the
sequestra and the interval of the eliminations, while the disease ia
prolonged for several months, and ofteji for several years.

The anatorao-pathological study of the few pieces which I have had
occasion to show you has shown us: —

1st. A first period, characterized by an injection of the periosteum
at the points where it had not been destroyed, by a concomitant
hyperaamia of the medullary organ, and finally by the dilatation of the
Haversian canaliculi of the compact tissue which may be considered
as a bypersemia or injection of the compact tissue.

2d. A second period, in which the vascalarized bone auppuratea
and increases notably in volume. Suppuration is found in the medul-
lary canal and in all the canaliculi of the compact substance, canaliculi
which are the principal theatre of the appreciable anatomical pheno-
mena of indammation of the bone. But at the same time certain
points of the compact tissue, previously bypertrophied, lose the vas-
cularization of which I spoke, and take a more or less eburnateJ
aspect which is explained by a diminution of vitality following the
augmentation which was indicated by the enlargement of the vascular
canaliculi.

Bd. A third period, in which the mortified portions are separated
from the rest of the bone by a groove, at the bottom of which lies the
pus whose formation coincides with the destruction of the bony tissue
which is intermediate between that which is necrosed and that which
remains alive. This period is more or less prolonged according as
the sequestra are or are not invaginaied, thatis, surrounded by living
bone, and according as the portions destined to die are more or less
numeroos, and succeed one another more or less rapidly.

4th. finally, a fourth period, which always appears late, and which
is characterized by the cicatrization of the fistulous openings, their
adherence to the bone, and the preservation by the latter of a greater
volume than normal.

What ia to be remarked in this evolution is the formation, from
the beginning and before the mortification is realized, of a hyperostosis
exactly similar to that which takes place in the cases of non-suppurat-
ing osteitis, and in which the parenchyma of the compact tissue shares
as well as the periosteum and the marrow. Now I cannot see in the
increase of size a reparatory procisss destined to replace the mortified
portions, since it commences before the necrosis, properly so-called.
Between plastic condensing osteitis of the long bones and suppurating
condensing osteitis, I find this (lift'erenoe, that the former takes place
without necrosis, and that the second is easily accompanied by necrosis.

Why and how is this difference i" The explanation is easy. I sup-
pose that in suppurating osteitis of the compact tissue the indaJutoA-

E NECROSIS OP THE LONQ BONSa. 221 ^H

n is severe, and \b followed bj the obliteration of a certain numbeT'^^|
vascular canaliculi bj the deposit of too abundant bony layers, that ^H
this obliteration may produce mortification at the points where it
takes place, and that the latter occurs particularly at the points
where the periosteum has been destroyed by the excess of the inflam-
matory process, the bone being deprived at these points of a part of I
its means of nutrition, while at the same time those which remain are J
compressed and afterwards obliterated by the diminution of the calibre I
of their protecting canals, I do not know if my supposition is correct, f
but in any case, no one can give in the present state of the science aa 1
irreproachable explanation of necrosis in acute suppurating osteitis. 1
The important thiup;, clinically speaking, is to recognize the pheno*^
irena, and not to allow ourselves to be turned from observation of ■
them by the acceptation of theories which themselves are only pre-1
sumptions, but which, instead of being accepted as such, pass,b]rl
being often repeated, for demonstrated truths. I

B^ In order nut to obscure your ideas upon this subject I must add I
^■hree more considerations: — |

^P" The first is, that, if suppurating osteitis of the long bones is often |
■accompanied by necrosis, yet it is not inevitable, and you v '"'
times see the first without the other.

The second is that the necrosis, that is, the mortified part, may be l
external or invaginated. The external- one is unquestionably thai
Kpiost frequent, doubtless because, as I explained it, the previous I
^■tlestrucnon of the periosteum by an inflammatory or a gangrenous!
^nrocesa contributes to the mortification. The invaginated form ia 1
lound when, the periosteum not having been destroyed, chance or
circumstances with which we are not acquainted cause the mortifica-
tion to take place in the centre of the compact tissue or very near to the
(medullary canal. It is the custom to say in such cases that the old
bone, or a part of the oM bone, is inclosed in new bone. That is true ia J
|eme exceptional cases, in those, for example, in which after an am-l
^utation the purulent osteo-myelilis has been followed by the morti-"
flcation of the whole thickness of the bime to a certain height, and in
which the remaining periosteum has furnished, under the influence
of ita excessive vitality, a new bony substance which forms in fact a
real new bone. In most of the other cases the invaginated sequestrum
is surrounded, not by a new bone, but by the part of the old bone
which has not mortified, which is hypertrophied, and of which the
hypertrophy, moreover, is not produced by the periosteum, since the
^^itter is habitually destroyed over a certain extent. Nor is it pro-
^Huced by the marrow, for that too is sometimes destroyed, sometimes
^Rtevaded itself by ossification, and because also it is too far from the
^aequeatrum for us to admit the formation by it of such a thickness of ■
bone as is sometimes seen.

, In short, it is the same with the hypertrophy of necrotic suppurating

osteitis as with that which accompanies the non-suppurating osteitis I

Kpf adolescents. Strictly speaking it is not the result of a special re- 1

^■Mratory process. It is due to the nature of the inflammation in the I

^K^npuet tissue. This nature doubtless intervenes when there is Fe>J

222 TKiUMATIC OaTElTlS AND NSCROBIS.

pair, as in the case of fracture. But ita intervention is no more a
benefit than is an erysipelas or a phlegmon in the cicatriziition of a
wound. I consider ihis augmentation of volume a superfluity, a com-
plication, and I consider it even as being one of the causes of necrosis
in long bones.

My third remark relates to the anterior condition of the constitution
of those who have, with or without suppuration, hyperostoses eon-
seeutive to osteiUs. In most of them the health was originaiiy goorl.
You will often hear it said that suppuration of the bones is due to
scrofula; that is true of the suppurating osteitea of the caneelloas
tissue of the short bones, or of the extremity of the long bones, and
I will show you, at tlie proper time and place, that this suppurating
osteitis of Bcrofiilous persons is at the same time rarefying, and that
if it becomes condensing, it is so only in places, and not over a great
extent, as is the case in condensing osteitis of the compact tissue. Wa
might give as an axiom this proposition, that condensation and hyper-
trophy, during and after osteitis, indicate a good constitution, or it
least the absence of the scrofulous diathesis. I do not mean by this
tbat patients do not die of an acute suppurating osteitis, for, on the
contrary, I have shown you that this affection sometimes causes death
by traumatic fever or by purulent infection; I mean only to say that
they do not die of exhaustion and of phthisis, as is so often the case
with patients affected with caries, that is, with rarefying suppurating
osteitis of the cancellous tissue. Should we go so far as to say thai
patients affected with necrosis oF the compact tissue never become
tuberculous or phthisical? OF course not; I admit that they may
become so; but it ia occasionally, after the deterioration of their
health by an abundant and prolonged suppuration, much more than
by an original disposition. In a word, if necrosis can give rise to
the lesions of the scrofulous diathesis, it ia not, generally at least, the
scrofuious diathesis which gives rise to necrosis.

The object of these general considerations, gentlemen, was to prepare
you to grasp the details concerning a patient affected with necrosis of
the humerus, in whom the suppurating osteitis, terminating in mortifi-
cation, is not of traumatic origin like that of which you have seen so
many examples after gunshot wounds. It is of spontaneous origin,
and although it began at the age of eighteen years, and although iu
this respect we have in it another of the so frequent examples of
spontaneous suppurating osteitis of adalescence, yet the disease has
differed from what it ordinarily is, under these circumstances, by a
much less acute, slower, and milder- course.

The patient, who ia now 32 years old, says his disease began at the
age of is. At that time, however, as I just told you, he did not have
the acute or hyperacute form which we see so often in adolescents,
and which we see more frequently upon the bones of the lower limb
than upon those of the upper one. He knows of no particular cause
to which this origin can be referred. He only knows that an abscess
formed slowly on the outer aide of the right arm, and that this abscess,
after having opened spontaneously, remained fistulous. He came to
me in IboU, three years aller it began, when he was iwenty-one yeMW

NETKOSia OF THE LONG BONKS, 223.

old, and I treated hiin at the Hopilal Cochin, where 1 had charge of the^j
surgical service. I felt with a probe a (Jenuded and movabie portion'
of bone at the bottom of ths fistulous tract; I mside an incision, witb--
drew llie sequestrum, which was superficial and not invaginated, and,
with the hope of modifviiig the vitality of the bone, I cauteriaed it'
with the hot iron. Notwithstanding that, the patient left the hospital
with the fistulous openings, which he has retained for ten years, and
you see thena to-day (2'A Feb. 1870), five in number, upon the superior
external portion of the right arm, for the bony lesion occupies the
upper fourth of the shaft of the humerus, without at the same time
interesting the head of the hone.

Notwithstanding these fistulse through which the pus continually
flows, the patient is hearty and muscular, and for the last ten years
has done, almost without interruption, the heavy work of a mason. >
But, annoyed by this continued suppuration, he has again come to'
ask my care.

A probe passed into these fistula; finds a portion of bone denuded
over a certain extent, and giving on percussion the dry sound and
the sensation of hardness which necrosis presents. The sensations
perceived are very distinct; it is a necrosis, there is no doubt remaining
upon that point; but I should like to be enlightened upon two others:
If the necrosed portion is movable, and if it is or is not invaginated.
Yon understand the important bearing of these questions upon the
method of operation. For, if the sequestrum is invaginated, it will
be necessary, in order to remove it, to open al! that portion of the
Btill living bone whieh surrounds it. I made in your presence the
examination needed to clear up this point. You saw that it gave me
certain results only at the end. I felt at the beginning indistinct
mobility of the denuded and sonorous portion, but I did not know if
I ought to regard that mobility as real, or attribute the sensation to
the bending of the probe. To remove this chance of error I abandoned
the probes, and made use of grooved directors. I introduced two of
them by difierent orifices, and leaving one of them loose in the fistula,
I tried with the other, which I held in my right hand, to move the
bone in which I suspected mobility. I at once saw the loose director
move freely, and these movements could have been given to it only
by the portion of bone upon which the other director was pressed,
and proved clearly that this portion was movable.

The mobility of the aeque.strum being recognized, it remained, as
I told you, to know whether it was invaginated or external; I iaclined
towards the latter opinion, but in view of the possible existence of
invagination I prepared the instruments necessary to hollow out the
bone.

The patient was anesthetized with ether; I made an incision over
the deltoid; uncovered the sequestrum, the mobility of which became
still more evident when my finger touched it; then seizing it with
strong forceps I drew it out. It was about an inch long, and three-
quarters of an inch wide. Then introducing my finger into the wound
to see if there were other sequestra, I felt none at first, and found
oa]y a large gutter in the humerus. It had been occupied by tbe'

224 TRADMATIC OSTEITIS AND NECROSIS.

sequestrum I had just removed, and its very smooth walls were
covered by a pyogenic membrane. But at the lower part I felt a
moviible piece of bone, which projected through an opening at the
bottom of this gutter, and seemed to occupy the interior of the
humerus. I seized it with a pair of dreawing forceps, and drew out &
sequestrum much longer and larger than the first. Tl was iuvaglnated,
and occupied in the thickness of the bone a canal which opened at
the top into the gutter of which I have just spoken. The opening
had been large enough to allow the fragment to pass. I again explored
the different hollows of the wound, and withdrew two more splinters;
I could ieel no others, but, notwithstanding the care with which I
sought for them, I cannot affirm that none remain.

Will this operation suffice to bring about a radical cure? I do not
dare to hope so, for these affections are extremely long, and pass many
times through the same phases before getting well. As I lohj you,
there are splinters which may escape notice, and, on the other hand,
new portions of bone may subsequently mortify and cause fresh in-
flammation. In children, these osteites wilh suppuration and necrosis
disappear generally at the end of three or four years, leaving only the
hyperostosis behind them. In adolescents, they last habitually until
adult life, that is, until the age of twenty -five or twenty-six years. In
this respect our patient is exceptional, for he has retained his bony
suppuration and necrosis until he has reached the thirty-second year
of his age; perhaps that is due to the fact that the disease was oot
very acute at the beginning.

Before going further, let me show you what there is peculiar and
diliicuU in the etiology and pathogeny of this necrosis, and also in the
anatomical form which it presents.

As to the etiology, I shall say nothing more about the absence of a
known occasional cause. I tell you only that, although resembling
traumatic necrosis, such as we see after gunshot wounds and compound
fractures, it is spontaneous, and commenced at the period of adoles-
cence, but without presenting the acute or hyper-acute form which we
sometimes see at that period of life. I will remind you also that this
patient has neither commemorative nor present signs of scrofula, that
nothing in him indicates tuberculosis, and that if there has been
intervention of an internal cause, as I am willing to admit, it remains
unknown to us, and belongs to none of those which characterize the
generally accepted diatheses.

As to the pathogeny, the mortification which occupies the compact
tissue of the upper part of the shaft of the humerus coincides, as you
may have discovered by comparing the size of the two arms, with a
notable augmentation of the volume of the humerus, so that you have
here another example of that triple iesson of which I spoka a moment
ago: suppuration of the hone, its necrosis, and its hypertrophy.

As for the anatomical form we had, at first, an external sequestrum,
the one which I first withdrew, then an invaginated sequestrum, the
second one withdrawn. It happened that the opening in the living
portion of the bone was large enough to allow me to reach and with-
draw the invagiaated piece through it.

NECROSIS OF THB LONG BONES.

Eemember that it ia not always thus, aniJ tliat when the openini

I too small, we are obliged to enlarge it wilh a gouge and mallet.

Iflhali tell you in a moment that, so far as the uonsequeucea are coo-

Icerneci, it is better not to have thus attacked the surroundiog bone.

iBnt is this aorroumding bone of new formation, or is it formed of the

I original bone which has remained alive and ha3 become hypertrophied

I in its superficial layera? Certainly, I cannot give you in thia case a

I rigorous demonstration; but, if you remember the considerations

which I presented at the beginning, you will admit hypertrophy of

the original bone aa at least possible and even probable, and you will

not admit as proven (for nothing proves it) that it is a new boue

formed by the periosteum. Finally, you will see in the bony hyper-

■ trophy a result of the suppurating osteitis and not a salutary effort,
^Bjuet as mortification at certain points of the same bone has been
^Ranother result which is neither more nor less salutary than the formei
H- Let us now examine the prognosis. Well, I admit that I do not
Biear the consequences of the operation. You will perhaps think that
H I am too bold in saying that, for this morning the suppuration was

■ fetid, and you know that fetid suppuration of bone may lead to
1^ dangerous septicBsmia. But what reassures me is, that I have madi
I no fresh solution of continuity in the humerus with the gouge ant
P mallet. Experience has taught me that dangerous traumatic fevei

and purulent infection are consecutive eHpeoially to osteo-myelitis'
caused by a recent solution of continuity, and the putrid form of
oateo- myelitis does not occur when, as in the present case, the bone
has been spared.

I do not, however, shut my eyes to the fact that this preservatioi
of the integrity of the humerus has its disadvantage, the existence ii,
the interior of the bone of a canal closed below and open at the topj
It will be difficult to prevent the pus from collecting in thia canal"
and it may become necesaary to make a counter- opening with a dril"
so aa to prevent stagnation of the liquids, and thus cause that
...iag solution of continuity which predisposes to pyternia.

But, on the other hand, it is possible that the bony canal may be-
lorae filled by the continuation of the hypertrophic process, and that
he formation of pus may cease without having caused any accidents.
However that may be, there ia, in the persistence of this canal, which
ps about an inch long, a disadvantageous condition which may keep
atp suppuration and hecticity, and prolong the afiection. This condi-
feon does not exist when the sequestra have been superficial, and in
aiis respect the prognosis has a greater gravity in thia patient than "
lie necrosis had not been invaginated.
_ (The patient afl'ected with necriisis of the humerus had no fevei
and presented no complication. The wound made by the operatioi
suppurated, the bone itself continued to suppurate, the pus flowet
with difiiculty from the canal in which the sequestrum had beei

IJodged, We made injections of a weak solution of carbolic a< '
pvery morning and evening,. by passing a gum catheter attached
tiie canula of the syringe into the bony canal. The patient wishet
to return home, and we showed him how to make th e iajeotiona.

yper-

'ffort^H
beeJ^I
'mer^H
■1 not^

hat

vas
to

itiS^^

of
)ne

ioq^H
ri^H

226 TRAUMATIC OSTEITIS AND NECROSIS.

I am still unwilling to propose a counter-opening, because this
operation might have unfortunate results, and because I hope the
canal will dry up or fill by the addition of new bony layers. If this
does not take place, if the suppuration continues, if it becomes more
fetid, if the patient is unable to work, he will return to us, and then,
recognizing the inability of nature to complete the cure, I shall make
a large opening at the bottom of the accidental canal so as to prevent
the stagnation of the pus.)

PART IV.

TRAUMATIC FEVER, PYEMIA, AXD SEPTICAEMIA.

LECTURE XXIX.

TRAUMATIC FEVER.

Qanaliot wound of the right ellioir — RHaaation Tollowed promptlj by dentil froifl
tntUTiiatiB fever — CondideratLODs upon grave trauiDAtio fever faltoning aoniponaj
fnotam.

Gentlemen: We lost yesterday a paiient wbo was struck at the
battle of Montretout by a ball which passed through his right elbow,
causing a comminuted fracture of the three bones formiti^ the articu-
Intion, He was brought to the hospital the next day.and on the fol-
lowing morning, thiriy-aix hours after the accident and while the
fever of the first period was still moderate, I resected the elbow.
You remember that the bones were so shattered that I found it very
difficult to remove all the fragments, since most of them were still
adherent and had to be separated one by one from the muscular and^
aponeurotic fibres, I made a T-shttped incision, the vertical portioa
of which was on the outer side of the arm and forearm, and the horiv
zontal portion posterior, passing above the olecranon. This incisioOi
is similar to that adopted by Roux,' but differs from it in this: thati
in the latter the vertical incision is on the inner side, while in thttj
one which I used and which belongs to M. N61aton, it is on the outet:
side. This enables the operator to reach the radius immediately anfii
resect it, and then, huving thereby opened the articulation freely, to
isolate and remove, while avoiding the ulnar nerve, first the upper
extremity of the ulna and then the lower extremity of the humerus.
In this case the operation was not as regular as it would be under
many other circumstances, for after having made the external in-
cisions, I came upon a mass of splinters which I removed without
knowing to which bone each belonged, and then I sawed oflf the end
of each bone so as to substitute a regular and uniform surface for the
irregular and jagged one due to the injury. You remember that '
then brought the edges of the solution of continuity together wil
four points of metallic sature, rather with the view of giving them
Heood position and immobilizing them than in the hope of obtainin
Hjwnmediate union. Indeed the latter is very difficult to obtain, am

^^^^^^ ■ Thore, ReaeclioQ da Coade, Inaufjiiral ThesU, 1B43.

TRAUMATIC FEVKB, PYEMIA, AND 8KPT10^B1A.

^B experience has tauglit us llmt immediate union after large operations
" almost always fails, and fails in the same wiiy, tbat is, because if by
chance it takea place in the outer or superficial layers it does not in
the deeper ones, where the fetid pus accumulates and is retained more
easily in consequence of the union of the edges of the wound and
the formation of a cavity behind them. Now this retention of fetid
pus behind a closed wound favors that absorption of putrid substances
which ia the starting point of infectious fevers. My intention then
was not to seek an immediate union, which from the moment it became
impossible would have offered only disadvantages, and the sanw
principle guides me after amputations, as I have had and shall doubt-
leas again have occasion to show you.

After putting in tbe sutures I placed the limb in a wire splint
properly lined with cotton batting and oiled silk. You know that
this splint is a recent improvement which we owe to those skilful
manufacturers, Messrs. Kobert & Colin. It has on the outer side a
movable piece attached to the rest by straps and buckles, which can
be removed and replaced at will. We removed it morning and even-
ing to dress and clean the wound, which was done without commu-
nicating any movements to the limb and without causing any pain.
The dressing was completed by means of a double compress soaked
in a mixture of alcohol and water and renewed every morning and
evening.

You remember what followed. The next day the pulse was 130;
the skin hot; the thirst intense. The patient had no appetite; had
not slept; complained of headache, and was very auxious about him-
Belf. The wound and the adjoining parts were very painful; the
lower half of the arm and the entire forearm were considerably
swollen. I removed the compress wet with alcohol and substituted
poultices; prescribed a potion containing one and a half ounces of
the syrup of the acetate of morphia to be taken by spoonfuls, and an
opium pill at night.

>The following day the conditions were the same. The abdomen
became tympanitic. The wound yielded an abundant sero-sanguino-
lenc discharge, and was covered with a grayish diphtheritic pulp.
The third clay the fever still persisted; the pulse was 130; tem-
perature in the axilla 104° (Fah.); tougue slightly dry; sub delirium
at times; increase of the local swelling. The sero-sanguinolent dis-
charge had given place during the night to a hemorrhage, en nappe,
whiiib evidently came from the capillaries. As it was not possible to
apply a ligature, the flow had been arrested by means of charpie wet
with dilute perchloride of iron and a band which included the splint
in its folds.

The fourth day still worse. Fresh hemorrhage during the night;
the wound covered with pulp and sloughs; the swelling of the deep
diffuse phlegmon in the arm and forearm had become enormous.

The following days the general and local conditions grew worse;
he tongue became drier; the abdomen more and more tympanitic;
the delirium continuous, and finally death touk place at the beginning
F the seventh day. ^^

TKAUMATIC FEVER.

We had in thia case, gentlemen, an exaggeration of the pheuomenn I
rVhich we often observe in the first period of large wounds which, if 1
the patients survive, suppurate and granulate before cieatrizaiioD. j
You remember that in gunshot wounds involving only the
parts, I have applied the term preparalory to suppuration to this perio^B
I .which most of our authors have called inflammatory. It is true thati,9
iwhen the bones are not involved the suppuration is always precedeij
!jly local phenomena of inflammation : slight swelling, heat, moderate*
^ain; but ordinarily the general symptoms, especially the fever, ure J
Absent. On the other hand, when the skeleton, as well as the soft
i injured, this period preparatory to suppuration is almost
idways marked by general and febrile as well as local symptoma, so
that it more than ever deserves the name of inflammatory period, I
say almost always and not always, because the general symptoms arei
sometimes lacking, and that occurs in the fortunate oases in whioh 7
the skeleton itself, the bones, and the synovial cavity, when a joint |
18 involved, do not suppurate, I have had occasion to call your atten? I
tioo to cases of this kind, and as the result of observation of such I |
offer this formula: intense fever appears in the first period of com- '

I pound fractures where suppuration is preparing in the bones them-
pelves, and it is lacking when the bones are destined not to suppurate.
^ Have we now any special names to designate this group of local
ftnd general symptoms? If you often hear me ask this question of
Nomenclature it is because the words are associated with ideas and i'
jheoretical explanations witli which we ought to be acquainted and |
from which we have even to choose when these ideas and those ex- I
planations lead to therapeutic or prophylactic measures. I have tolelr'J
you before that the term hospital gangrene has sometimes been applied 1
to wounds in this condition, and also that I did not approve of ik.l

tLet us seek one that is more appropriate.
r After Hunter's and Broussais's works on inflammation the dent
nation of inflammatory period, which I have just mentioned,
Suiopted, By this was meant that the suppuration depended upon ft4
peculiar condition of the wound and of the entire organism calle^
ioflammation. When the fever was lacking, or was not vary higb^
they said the inflammation was moderate; when the fever was \
■finarked, it was explained by the intensity of the inflammation.

, A little later, aijout 1810, surgeons began to express some doubtt
f the aufBciency of this explanation of the symptoms which preceda
^d seem to prepare the way for suppuration. Without giving anfl
isons, they adopted new terms wliich seemed to indicate another^;|
Hit still vague and indefinite, theory.

' This is seen in an article published in 1848 by an English surgeon,"'
fenwick, in which the causes of death after amputation are discussed;
jwalhs ooeurring during the first ten days instead of being charged to
^<too intense or malignant inflammation are attributed by this author,
wme to nervous complications, the others to gangrene of the stump.
Fenwick has certainly included under this head of nervous complica-
tion thoae cases ia which the patients were delirious, and under that

230 TRAUMATIC FEVER, PYEMIA, AND SEPTIO^MTJ?

of gangrene those in which the wounds presented in a very marked
degree the slougha and pulp which yon saw on our patient. More-
over, as Fenwick'a stabislics were taken Prom the records of different
hospitals, and were of patients whom he himself had not treated, he
had to take as the causes of death those assigned by the surgeons in
charge, and they wrote the words nervous complications or gangrene
according as their attention was attracted more by the delirium or by
the slongha. That meant that in their opinion death was due to a
conoomitant cerebral affection, or to gisnurene, but they did not explain
the intervention of this as a cause of death.

Since that time we have had other American and English statistics
which still attributed the deaths of this first period of capital opera-
tions to one or the other of these two causes.

Still later, about 1850, and stil! without giving any positive expla-
nation, the German surgeons, and Billroth ia particular, made use of
the term traumatic fever, and attributed to this fever that which in
France we had first attrihuted to inflammation, and that which Fen-
wick and the English had afterwards attributed to nervous complica-
tions and to gangrene of the stump.

Then came the experiments of Otto Weber, those of Billroth
himself,' and Panum's. These experiments consisted in the injection
under the skin of different animals of aanious and putrid discharges
coming from patients whose suppuration was of bad character, and
then in watching the subsequent condition of the animal by means of
the thermometer. It was found that in almost all cases tlie tempera-
ture rose severaldegrees, that some of the animalsdied, and the others
recovered after having been sick for several days. The experimenters
inferred that the passage of putrid substances into the blood can cause
feveriand they "explained by this passage the so-called traumatic fever,
so that at last this term came to convey the idea of an infectious fever
due to the absorption by the lymphatics and bloodvessels of the wound
of the putrid materials found upon the surface of the latter.

Before the experiments of the German authors were made, T had
worked out the same solution of the problem, and I said in the paper
which I read in 1S55 before tlie SociiSt^ de Cliirurgie that the fever
which sets in during the early days of a large wound was due to an
infection, that is, to the passage into the blood of putrid materials
having their origin ia the decomposition, by contact with the air, of
the sanguinoleut, serous, and seropurulent liquids poured out daring
the first hours, before the complete establishment of suppuration, and
absorbed by the vessels of this wound. I was led to this opinion by
two series of experiments. The first were made upon human beings
by applying the iodide of potassium to wounds with the view of
studying their power of absorption, I found this power was very
marked, and as, on the other hand, I oft,en found putrid liquids during
the preparatory period, I did not hesitate to infer that these liquids
might lie absorbed, and, passing into the economy, produce fever.*

TRAUMATIC FEVER.

2S1

Era were made upon animiils; the akin was incised, and
It and fetid pus, procured from fresh amputation wounds,
was introduoed below it and retained by three or four points of sature.
I did not take tlie temperature, but I found that the animals (dogs)
became ill and died promptly, while others inoculated in the same
way with phlegmonous pus, that is, pus not coming from an acute
osteitis, survived, and, indeed, were scarcely affected at all.

I admit then that the German experiments have been of service to

this new theory, because they were more numerous, and more widely

Kpublished than mine. But I may be allowed to repeat what I said ia

^Bhe Acad^mie de M6decine,' that, so far aa I am concerned, I did not

^nrait for the results of foreign work before expressing my opinion

Upon this subject.

To-day, adopting the word septtccemia for all the febrile conditiona
which we are authorized to explain by the passage of putrid sub-
stance into the blood, we say that traumatic fever is a septicemia,
the traumatic septicEcmia of the first few days, as distinguished from
the purulent infection which occurs a little later.
Two questions arise here : —

Are alE the aymptoma observed during the first period of wounds
which are destined to suppurate due to septicemia?

What ia the origin of the putrid poison the absorption of which
^jives rise to traumatic fever or primitive septicsemia?
^L 1. We must distinguish three varieties among the symptoms of
^Bhis initial period of wounds,

^T The first, which we find especially in the eases in which the eola-
tion of continuity involves only the soft parts, is that in which the
symptoms remain local and are not accompanied by fever.

The second is that in which, while the local symptoms remaio
ui(l>iite moderate and the surface of the wound especially does not
pecome gangrenous, a certain amount of fever is nevertheless present.
Ifhis is what I call mtld or benign iTaumalic fever; it is seen in some
ases of very extensive wounds interesti.ng the soft parts alone, and
1 some of those in which the bones are involved and are destined to
uli&re in the acute suppuration, but without putridity,
V The third is that in which, the bones being involved and about to
become the seat of acute suppurative osteitis, the surface of the wound
becomes gangrenous, a deepseaied, fetid, diffuse phlegmon is devel-
oped, and fever sets in and takes on a very serious form. To this I
ffive the name grave traumatic fever or esaeilialiy malignant primitive

Kp&asmia.
I do not wish to affirm that aepticsemia really exists in the first
ariety ; indeed I am inclined to think that it does not, and that the
local symptoms should be attributed to a group of local anatomical
conditions or modifications which are necessary to the establishment
of the pyogenic membrane and the suppuration, a group to which we
can give no other name than the one by which it is now known in

t
I

n purnleute, (Bull, de I'AcRd. de Mudeu

232 TRAUMATIC FKVKB, PYEMIA, AND SBPTIC^MIA.

pathology, that oF inflammation. T will say then thnt in such a case
suppuration is preceded by a purely inflammatory period.

In the second variety where there is fever, but a mild one, I am
more ready to admit a certain degree of septiciBmia. It is true that
local inflammation exists, but it ia not sufficient, I think, to aacount
for the fever, and when I see this coexisting with the presence of
more or less putrid substances upon an absorbing surface, I am dis-
posed to consider it due to absorption, and consequently to sepli-
Cffiniia.

As for the third variety, I do not hesitate a moment. The intense
and dangerous fever coincides with extreme putridity of the wound;
the symptoms observed accord with those furnished by experiments
npon animals. The absorption seems no more doubtful to me than the
septicremia which is the consequence of it. It would remain to deter-
mine whether the gangrene of the soft parts, which would then have
to be attributed to a bad character of the inflammation, precedes the
septicEemia and is the cause of its gravity, or whether it is the inten-
sity of the aeptictemia which reacts upon the wound and leads to
gangrene.

We here touch upon questions which can be answered only by
hypotheses supported neither by experiments nor by analogy. For
that reason I shall ofter you no definitive solution, wishing simply to
leave you with this impression that grave traumatic fever owes its
gravity to the extreme malignity of the putrid poisons formed upon
the surface of a wound in a certain number of cases where these
wounds are complicated by the imminent appearance of acute suppu-
rative osteitis.

2. I asked a second question: What ia the origin of the supposed
poison which gives rise to the septiciemia of traumatic fever?

The authors who first spoke of putrid absorption, and who pre-
pared the doctrine of septicaBmia, confined themselves on this point
to generalities, saying that the poison was formed by the decomposi-
tion in the presence of air of the aerosity and blood exuded from the
surface of the wound during the first few days, and they spoke of the
poison as if it might be formed, and with the same facility, on the
surface of every wound.

Now, if my idea has been properly expressed, you must have
understood that, if I admit the existence of inflammation during the
first period of all wounds, I am far from admitting septicsemia in all,
and that, if I admit it for some, I make a distinction between benign
septiciemia or mild traumatic fever, which is never fatal, and grave
septicemia, which often causes death. You must also have under-
stood that grave septicsemia is rarely seen in cases where the skeleton
is not involved. We see it especially when there is fracture of a large
bone at the bottom of a wound caused by a gunshot or by some
bruising body, and when this bone is about to take on acute suppu-
rativa inflammation of all its constituent parts (periosteum, bony
substance, medullary tissue, or marrow), or when a large arliculatiou
ia widely opened and becomes the seat of acute suppurative synovitis.
So that in my opinion the problem is restricted to this : What ia tbao. ■

TRAUMATIC FEVEB. 233

the origin of the supposed pniaon in the cases of osteitis and trnu-,
matic synovitia, which, together with the coexisting wound, are to
pass through acute suppuration?

A. As for the cases of osteitis, T have often explained to you the
opinion which I first expressed in 1855,' that the medullary fat ia
probably the origin of the poison. When a bone takes on acute
osteitis, the marrow shares in the inflammation, to which I am always
obliged to concede a certain part in the evolution of the symptoms
preceding the establislunent of suppuration. Tliia marrow becomes
hyperiemie, infiltrated with blood which escapes from its congested,
vessels, and with plastic matter exuded by these same vessels; parBi
of the fat and of the albuminoid substances which form the marrow"
escapes and mingles with the serosity, the clots, and the exudations.
AH this decomposes as tlie result both of the admixture and of an action
of the air similar to that which produces pntrefaction. I wish I coald
help you to see and touch this peculiar alteration of the fatty subatanca
of the bone; but I cannot do so, for chemistry has not yet given a final
opinion upon the subject. I have, however, read an article by M.-
Kloae of Breslau,^ in winch he speaks of the special alteration of tho*
fat of inflamed bonea and of the putrid principles to which it gives,
rise. I admit that I have no positive demonstration to offer you^
but how are we otherwise to account for the frequency, and above,
all, the gravity of septicteraia in those cases in which the bones
purate? I know that fat ia to be found in the soft parts, and that
it would seem aa if this fat ought to change in the same way as in
the cases where the bones are involved. But the fat of the soft parts
has not the same composition, that is, it is not combined with the
same albuminoid or gelatinous substance, the presence of which
perhaps renders the decomposition of the fat of the boues easier and
more deleterious; moreover, I have told you that traumatic fever
sometimes occurs also during the first period of wounds of the soft
parts. It may be because their fat does not furnish such pernicious
substances that this fever is rarer and more generally mild. But it
is none the less allowable to explain it also by a certain degree of
septicaemia, admitting that the organic poison supplied by the altered
fat of the soft parts is a little different, or, if it is the same, that it is
formed and absorbed in leas quantity.

In 1855 I ventured another supposition, that, the poison being the
same in the traumatic fever following lesion of tlie soft parts as in
that following lesion of the bones, its greater gravity in the latter was
the result of a more ready and more abundant absorption, due either
to the fact that the solution of continuity of the bone increased thtf
extent of the absorbing surface, or that perhaps the marrow itself
possessed a very great power of absorption. 1 published the results
of several experiments upon dogs, in which I trepanned the shaft of
the femur, and injected through a syringe a preparation of iodine into
the medullary canal, results which showed that the marrow
the power of absorption, although not to a greater degree than
parts of the organism.

I
I

other ^^^

234 TRAUMATIC FEVER, I'YJBMIA, AND SEPTICEMIA.

The reaults of recent experiments communicated by M. Demarquay
to the Academic de M^decine in October, 1871,' are more favorable
tban mine were to the opinion that a rapid and easy absorption takes
place wiibin the medullary canal. These experiments consisted in the
iiijeclion of fuchaine by means of an Aiiel syringe through a hole
made between the condyles of a rabbit's femur.

B. As for the cases of synovitis, I shall first make a distinction
between those in which the peoetrating wound of the articulation is
complicated by fracture, as in gunshot wounds, and those in which
fracture does not coexist. Intense traumatic fever is rarely absent
in the first case; but it can be explained, in part at least, by the acute
suppuration of the fragments. It is not so intense nor so grave in
the second, but it nevertheless exists, and is more marked than in
ordinary wounds of the soft parts.

Whence comes the poison then ? Probably from the altered fat of
the synovia; but perhaps the extent of the absorbing surface must be
considered, especially when a large articulation is involved. I may
add that liquids are retained and stagnate easily within the cavity of
an articulation, and that consequently when once formed the poison
is brought into contact for a longer time, and more freely with the
large absorbing surface.

Etiology, Prophylaxis. — We have discussed the pathogeny, the ulti-
mate mechanism, that which is so difficult to grasp in all diseases, and
I wish now, returning to the practical standpoint, to speak of the
etiology, of the appreciable causes of traumatic fever. And yet I
should tell you at once that I have very little to say. You Itoow
that the principal cause of this affection ia a solution of continuity
involving the soft parts and the bones. But all persons who receive
wounds of this kind are not sure to have the fever, and among those
who are attacked by it, some are but slightly affected, and others so
severely that they die speedily. Do we know the reasons of these
differences? Very slightly.

I can again tell you that traumatic fever is absent, or is moderate,
in the rare cases in which the bonea do not take part in the suppura-
tion. We have had several examples of this, and I have discussoil
it sufficiently on other occasions. But I do not know what are the
causes which favour this suppuration, and make it inevitable in raoat
cases. However that maybe, acute purulent osteo- myelitis having been
set up, the causes whicli aggravate traumatic aepticiemia are probably
all those which may have deteriorated the constitution shortly before the
wound was received, such as fatigue, privation, bad food, loas of sleep,
forced marches, moral emotions, chagrin, all those circumstances, in a
word, which afiect the soldier, and give a special gravity to gunshot
wounds of the large bones. I believe, however, that bad domiciliary
conditions in the hospitals, and notably the hygiene of the wards,
exert but little influence. After the IJattles about Paris, I so often
saw grave traumatic fever make its appearance in large rooms, or in

' Ditmarquitj, Realierahes ear la Perm6sbillt£ des Oa dsns gas repporte tat I'OtUo*
mrfitite flt I'lufHotiuu parulente. (Bull, da I'Au^d. Ae M^deoiue, Ootobre, ISTl, \Qm9

TRAL'MATIC FEVKR.

235 \

we 11 -ventilated and not crowded military hoapilab, that I cannot admit I
that bad atmospherical conditions have any influence in producing it, |
at least not so certainly as they have in purulent infection. >

In addition to the nature of the wound, and all the individual con-
ditions which I have enumerated, we can only invoke, to explain ths I
intensity of the traumatic aepticEemia, as we do for so many other I
diseases, an idiosyncrasy, that occult cause of which I have spoken so f
often, in consequence of which certain persona are more apt to supply,
from the liquids of their organism altered by contact with the air, or I
by the consequences of a violent inflammatory process, the quantity- J
and quality of septic poison necessary to compromise life. j

From what has been said I wish to draw the conclusion that, in the J
present state of our knowledge, we possess no real prophylactic mea-
sures to be employed against grave traumatic fever.

The best plan, when a patient has received a compound fracture, i
to do everything that may prevent suppuration of the bone. To |
obtain this result in gunshot fractures, we cao do little beyond im
bilizing the limb and the fragments, and taliing the special precautions I
which are necessary during the removal of the patient from the field \
to a more or less distant place.

As for the constitutional conditions of which I have spoken, and 1
which predispose to dangerous suppuration, it is plain that we can do I
nothing against them, and that no prophylactic measures could oppose j
their influence.

It is always well, especially in view of purulent infection, which,
next to grave traumatic fever, threatens the patient mo.st — it is well,
I repeat, that he should be placed in as pure an atmosphere as possi-
ble which can be renewed easily and without chilling, and if possible,
in a room which contains no other wounded patient. From what I
have said, you may have comprehended that this precaution is not so
necessary against traumatic fever aa against purulent infection, but ao I
long as isolation is a precious prophylactic measure against the latter, J
it will inevitably be used against the former. I have returned to this I
subject in order to leave this idea in your minds, that, if we are |
authorized in our statistics to attribute the mortality caused by puru-
lent infection to bad atmospherical conditions, yet we must not I
attribute that caused by traumatic fever to the same cause, since it is j
due rather to individual than to external conditions.

There is, indeed, a prophylactic measure to be found in a mode of
dressing which we should always bear in mind when we wish to pre-
vent a suppuration, the consequences of which may be serious, I J
refer to the occlusive dressing, whioh I have often had occasion
mention, and which you have seen me use successfully. Its result '
may he either to suppress all suppuration or only that which is
dangerous, suppuration of the bones, by favouring ihe union of the
deep parts and allowing suppuration of the superficial parts alonfe.
But, although this dressing succeeds perfectly when the wound is
small and when it has been made by an ordinary instrument, it ia of
no use when the wound is so large and contused as it is when caused
by a gunshot. Cuasequeotly yoa have never Beea me use it Id c

2ab TRAUMATIC FKVBS, FY^MIA, AND SEPTICEMIA.

oF tbis kind, and I have abowa you tbat wben patients bave oeca-
Btonally esoiipsil suppuralion of ibe bone after ganshot wounds, this
■ rortunale result could not be attributed to our method of dressing
the wound, but was due simply to the idiosyncraay of the patient,
the immobilization of the limb, and abstention from irritating explo-
rations.

Finally, do not be surprised that T do not speak of curative treat-
ment; there ia none that has much influence upon this dangerous
affection. Derivation towards the alimentary canal by means of laxa-
tives is always indicated, also nleoholic stimulation, and even sulphate
of quinine and tannin as antiseptics. You have suen nie employ
these, but your observations and mine have shown that they were nut
very effiuufioua.

LECTURE XXX.

PUBCLENT INFECTION OR PYyEMlA.

Two caeea of parnlent inrection or pfieinis,, attf. folloiriug guaahut fractare of tlis
thigh, the otiier, guushot frautureoF the leg — Anatomical aharactera and pa-
thogunj of this disuase.

Gentlemen: We have recently lost two of our patients who were
suffering from gunshot wounds. One had had the femur, the other
the tibia broken by a ball. In each case the fracture waa near the
middle of the bone and moderately comminuted. They suppurated;
the patients, who were both young but much broken by exposure to
cold, forced marches, and loss of sleep, had intensa traumatic fever
from the beginning, and, in one case on the ninth, in the other on the
eleventh day, had an initial violent chill which lasted twenty or thirty
minutes, and was followed by great acceleration of the pulse. The
tongue became dry, the skin clayey, and tben subicteric in color. The
chill was repeated once or twice each day at irregular intervals, the
strength grew less, slight delirium, diarrhcoa, and abdominal tympa-
nites set in. Meanwhile, the suppuration diminished, the pus became
thinner, and bad that fetid odor which you have heard me compare
to that of a mouse. Finally, death took place on the twelfth day in
one case, on the fifteenth in the other.

The autopsies were made, and I now show you some of the apeci-
mena taken from the bodies.

. I, The principal lesions were fouud in the chest, abdomen, some of
the joints, and the broken bones.

A. In the chesty each pleural cavity contained a notable quantity
of serosity, together with soft false membranes lining the parieltti
pleura and the lungs, especially at the base and the lower lub(

' PUHULENT INPKCrlOK OB PYEMIA.

After having takeu out the lun^s and removed the false membraneaul
T examined the upper aud middle lobes, without finding anythir
worth mention in them. Then, taking hold of the lower lobes, i
which lesions are most frequently found in case? of this kind, I felt|l
in the tissue of the lung along the outline of the base and behiiid'^4
several hard lumps about as large as peas, over aome of which the
surface of the lung was of a deeper colour than elsewhere, whilst
over others the colour was yellowish. On cutting into these different
points, we found different appearances. I here show you two of them,
in which the surface of seotion is black, and from which I can scrape
or squeeze a thick stieky liquid which is nothing but blood. But this
blood does not flow away freely ; after the scraping and squeezing
there is still enough loft to keep the colour dark and to give the 1
pulmonary parenchyma a firmer consistency al thesa points than e'
where.

Here are two other spots, in which you find the centre of the section.!
yellow and the outer part of the same deeper colour as before. Th»
yellow centres yield, when pressed and scraped, a small quantity o
liquid which to the naked eye seems to be pus, and in which thet
I microscope shows us purulent globules; but this pus does not flow
^way in sufficient quantity to leave a cavity behind. In addition toM
jhis rather scanty inSltrated liquid, there is a yellow substance, pro-f
(ably plastic matter, united very intimately with the parenchyma oH

' ^ ''"'^- ,-*

Lastly, I show you three other spots over which the surface itselH

SF the lung was yellow. On cutting into them you see real pus flow

Fellow and creamy like wholesome pus. After its escape there

s a cavity, here as large as a large pea, there as large as (

^lael-nut, the inner surface of which is still lined with a rather adhe-l

lent yellowish exudation. But the red and yellow centres have dia

ippeared, and with them all that remained of the parenchyma.

You see there, gentlemen, the three stages of what are calle(

IBetaatatic abscesses of the lungs; the brown foci belong to the first,,*

3 that are gray in the centre and brown at the periphery to thoT

(eeond, and the purulent collections to the third, The anatomicaa

"diaracters during the first two stages dift'er from those of ordinary*

"phlegmonous abscesses. In the first, for example, instead of a simple'

nyper£8mia with infiltration of seroaity, it seems that we have an

eochyniosis, that ia, a flow of blood from torn Ciipillarles, and at the

same time a thiclsening of this blood and an intimate union of its

Moagulum with the infiltrated portion of the parenchyma of the lung,

I Dance' and Cruveilhier,^ however, explained these brown foci ia

ninother way. They attributed them to small blood clots formed

nirithin the capillaries of the lungs in consequence of the developmeal^

Bof a capillary phlebitis. ^M

K Virchow^ and the German authors afterwards adopted this explaaivifl

■ 1 Dance, Article Abims mHtuatHtiqnea.littlie Blot, de M6d., in SO tdIs. Paris, IgS^H
B > CriiTBilijior, ArLluIu Hiil^ltita iu the Diat. d« Mi^dttuiue at Gliirurgid pintiqued, l^H
ml6 rolumoR. V

mt-' Virohow, Pathologie CellaUirs, Pttit, 180S, Sd edition. ^M

TRAUMATIC FEVER, PYEMIA, AND SEPTICEMIA.

tion oTthe formation of the brown foci by clots, but they added that
these clots, insteud of being formed locally, as Dance and Cruveiihier
thought, came from a, distance; that they were embolic clots formed
in the affected veins near the wound, swept alr>ng in the current of
the circulation, and stopped in the capiUaries of the lungs ; and they
invented the word infarctus, which bears the signification of an oh-
Btruction of the capillaries by fixed, but imported, clots.

I wish I could show you which of these two theories, that of
ecchymotic infiltration, or that of embolic clot, is the right one; bat
I cannot do so,

I see the thiek blood intimately mingled with the parenchyma of
the hings, but I cannot make out whether it is contained within the
capillaries or whether it is outside of them, and seductive as the
theory of embolism may be, I do not find evidence sufficient to make
me consider it irrefutable, as most authors do.

I can understand as easily the possibility of an ecchymosia analo-
gous to that which we see formed in the lungs after the ingestion of
narcotic and nareotico acrid poisons. I shall tell you in a moment
that I consider purulent infection as a septicismia, as a poisoning; it
is possible that the poison aots upon the lungs like those I have jnat
mentioned, that is, that it gives the blood qualities which are irri-
tatiag and corrosive for certain vascular walla, hence its escape and
infihralion. It is certainly ditfijult to anderstand why this corrosive
action should be exerted upon the lungs and liver more than upoa
the other organs, why in the lungs themselves the vessels of the basff
and those of the superficial layers of this base are more often and
more easily torn than those of the upper lobe and of the deep por-
tions of the lung.

This difficulty is, moreover, only the prelude of many others which
the study of this singular affection will ofter us. You will see ai
every moment that I shall be at a loss how to explain the vsrtoua
phenomena which characterize it.

Look, for example, at these yellow foci of the second stage. By
what are they formed? Probably by an e.'tudation of plastic matter
at the centre of the red spot. But whence comes this exudation ? Is
it, as the name would indicate, a new formation substituted for the
blood, which, origin'illy arrested, would ther. be reabsorbed ? la it
not rather a transformation of this blooJ? I cannot give you a satis-
factory solution of this question.

And then these cavities of the third stage, how are they formed?
la it again by a new formation, which would presuppose the absorp-
tion of the exudation just as its deposit presupposed the absorptioa
of the blood ; or might it perchance be a transformation of the original
exudation into pus? These are obscure questions, which I aak and
do not answer, although I do not hide from you that I incline rather
towards the theory of substitution than towards that of transforma-
tion.

B. In ike abdomen^ we found the spleen larger and more friable than
usual, and filled with very thick black blood. On the convex suvlaua
of ihe liver we found two yellow spots of about the sii^e of a dime;

PUBULKNT INFECTION OR PYEMIA,

239^

on catting them tijey proved to be formed of a concrete semi-soliii''
substance, resembling that of the second stage of pulmonary metastatio
abscesses, and which seemed to ns to be likewise formed of plastic
material mingled intimately with the tisane of the liver. ^Furthermore,
on cutting more deeply, we found two cavities within its parenchyma,
containing thick, yellow, creamy pus. Were these abscesses preceded
by a plastic deposit analogous to that which we found on the surface
of the liver? It is very probable, although in cases of pyjemia we
find metastatic abscesses of the liver more often in the condition of
collection than in that of infiltration. You notice here what
generally the case, that there are no brown spots similar to thoaa^J
which, in the lungs, characterize the first stage of metastatic abscesaea.'
The infiltration of blood, if it precedes, inuat then disappear very
rapidly. But as I have never met with it, even in cases in which
death took place very early, I believe that it is ordinarily absent, as ia.
also the case in the muscular interstices and the articulations, and
that consequently the embolic clots to which so much importance ia.
attached in Virchow's theory must not be considered as inevitablyi
preceding the formation of pua in abaceases of this kind. So long as
I we do not find sanguinoleut foci in the liver we are not justified in
■believing in a preliminary morbid condition, with or without rupture,
Epf a certain number of capillaries.

0. We opened the right scapulo-humeral articulation of the first
oatient. who had complained of pain there, and we found in it a con-
^derahle amount of pus. I culled upon you to notice: Ist. That this
1 thick, creamy, and presented, consequently, the charac-
teristics of what we term wholesome or laudable pus; 2d. That the
synovial membrane, notwithstanding this abundance of pus, presented
neither ecchymoaes similar to those which we found in the lungs nor
. the infiltrations, nor even the redness, nor the thickening which ia
irtieular abscesses of different origin indicate the existence of a

vitis ending in suppuration. In like manner, as you sa'
13*8063 of hepatitis below and about the abscesses in the liver, so yoa
fee here no traces of synovitis.

The same thing is seen in the cases in which we find metastaliq
libsceases among the muscles. There are coUectiona of pua, but about
KJbem we find neither injection nor serous infiltration, nor any of the
■flinatomical characters which belong to a phlegmon precedinj
l^lbfloess.

In a word, purulent collections without preliminary inflammation;

H^at is the most striking point in these so-called metastatic abscesses

■af purulent infection; for I cannot consider as belonging to inflam-

^matiou, properly so-called, the lesions of the first two stages of the

' pulmonary metastatic abscess. Theae lesions are unusual, bizarre, iC:

you choose, but they are not those of an ordinary phlegmasia. M

D, Here now are the femur and the tibia, which were broken bjij

the balls. Both otter the multiple fragments of comminuted fractures,

Lftnd these fragments lay in the fetid and blaokieh pua which comniu-

Jnicated with tlie e.\terior by the openinga of the perforating course

loliuwed by the projectile. The periosteum still remaiua on suuie of

240 TRAUMATIC FEVER. PT.EMiA, ANH SEI'TIC^MtA,

the fragments, but is lacking for about an iiicti on tlie two principal
ones, the upper and lower pieces.

If jou examine the outer snrface of the compact tissue of these
fragments, you will find there a little rerldening, and that enlargement
of the Haversian canals which was pointed out by Gerdy' as one of
the characters of osteitis of the compact tissue, Neither upon this
outer face, nor upon the fractured surfaces of the fragments, nor upon
what remains of the periostetim, do we find any appearance of the
process of consolidation. It is evident that the purulent secretion has
taken the place of the secretion and subsequent transformations of
the plastic lymph, which, at the stage of injury, if there had been no
suppurating wound, would have supplied the cartilaginous callus. If
the patient had lived, the granulations of all the surfaces of fracture
would have undergone this transformation, as I have previously had
occasion to explain it to you (see p. 76 et seq.),

I call your attention particularly to the condition of the medullary
tissue of the two bones. In order to understand it properly, T have
had recourse to two measures: I have broken the upper and lower
fragments of each of the fractured bones with a hammer, and I have
talren out and broken in the same way the corresponding bones (femur
and tibia) of the other side. I wished to show you the interior of
the medullary canals, and to enable you to compare the appearance
of the healthy with that of the affected side. "What do you see on
the healthy side? The medullary canal, and the meshes of the spongy
tissue which are continuous with it at the ends of the bone, are filled
with rather firm fat, very yellow in one case, pinkish, and at the same
time a little more diffinent, in the other. The predominant fact, not-
withstandiug the differences in appearance and consistency (differences
which are very common, and by no means imply an abnormal condi-
tion),' is the fat. Look now at the fractured bones: at the line of
division there is no longer any fatty marrow; in its place is a substance
red in some places, gray in others, blackish here and there, rather
firm, with a fetid odour, not looking at all like fat, hardly greasing
paper when rubbed upon it, and apparently composed of an exudation
mingled with what remains of the marrow. Scraping it with a scalpel
removes a puriform substance. At a little distance from the line of
division, we find here and there collections of pua, instead of the thick
substance infiltrated with pus of which I have just spoken, and that
continuesfor about one and a half inches beyond the point of fracture.
It is only after reaching the spongy tissue near the extremities that
we fiud normal medullary fat without admixture of pus. There is
then in the medullary canal a mixture of plastic deposits, of purulent
infiltration and collections, and of gangrene here and there, with
diminution and total disappearance in places of the normal fat. This
is somewhat similar to diffuse phlegmon with sloughs of the soft parts,

■ Geril;y. Muladios des Orgiines Sa Mouvement, p. 155, Paris, 1S55.
• Thu murrolr of Urn t>ODea id alvnya mnru raduiiUi and more dimnunt in tlie uliilil
nnd adolHsoeut tlinn in Ihe adult and aged, and, iu lUia rnspeut, there ere msixy iudl-
vidnsl varieties nmong adults; someiiuiBa the marrow is more, BOioeti uia* '
I rasmiar, SBtl Uiea» diOerenaei «» uat da« to appreoiable patbologlMl ovusea.

IPDBDLENT INFECTION OR PYEMIA. 241^^H

STie lesion which you find here is that which on other occasions T h^ivet^^^
bhown you under the name of putrid and dift'ase osteo- myelitis (see^|

■e

p. 316 et seq.).

E. Veins. — We examined the femoral vein near the point of fracture
of the femur, and found it filled with black iiiicoagulated blood, without
any sign of pus, and without the changes in tlie lining membrane
which we often see in phlebitis. We also examined the nutrient veiU',
at the nutritious foramen, an<i found that it also contained no pus and
no blood clot. Consequently, in this case, the purulent infection could
not be attributed to a suppurative phlebitis. We examined the tibial
veins in the other case; one of them contained soft and badly smelling
blood clots without pus; the others were permeable. In this also there
was no suppurative phlebitis.

II. I am naturally led by what has preceded to ask the pathogenioi
question; What is the cause of purulent infection, and what relntiooa(j
exist between these visceral, articular, and muscular abscesses, and th(

ppurating wound which preceded and doubtless caused them? Thai

a question which has occupied surgeons since the end of the last

sntury, and upon the answer to which they have not

;, for the very simple reason that, in this malady, as in many
others, such as most of the contagious diseases, a moment comes when
appreciable phenomena are wanting, and when we are obliged to eub-
Btitute an hypothesis for them, which some are willing to accept, but
which the oihers criticize or reject, asking for a demonatratiou which
no one can give them. The best plan, perhaps, in the preeeoce of
this difficulty would be to adopt no theory, and to wait until we should
possess one established upon solid '

I am not quite ready to adopt this plan, for a reason which I gaw
to the AcadiSmie de M&lecine at the time of the discussion on purulent
infection,^ that is, because we have effiirta to make to preserve tha
wounded and those upon whom we operate from this dangerous aife*-
tioa, and it is very diRieult to advance safely in the search for prophy*
lactic measures if wo are not guided by some idea of the pathogeny.
I We can group in three main classes the opinions which have beaa
peld upon the mode of development of purulent infection.
p '1st. Aletrisfasis nnd Absorplion of Pus. — The authors who first noticed
me connection between internal abaijesses and external suppurations,
especially Van Swieten, J. L. Petit, and Morgagni, spoke of the transfer
of the pus from the wound to the viscera, but without explaining tlia
manner in which this transfer was effected.

Afterwards Velpeau' and MarechaP were more explicit, and ex-
ihe opinion that the pus of a wound could be absorbed by
te open veins, pass thus into the circulation, be deposited in certain
, and there form the abscesses known as metastatic. This dots-

ne rested upon two incoutestable facts: the presence of pus in the

. irnllate (BqUhUii iIo t'Avtiilfiinle da MSdedna,
itaroh 27tli and August Itilli, 1871, toino mvi. pp. lS2iniii 620).

■ VxIpMau, QraduHlion TlmaiH, Iti'iS, and sareral arlluled ia tliu Ai
de Ulideaiax, in 1S24, 1821!. ftnd 1S2T.

* Uarealml, Qradoatioa Thasis, lB'2a.

242 TRA0MAT1C FKVKH, PY-EMIA, AND aKPTlC-EMIA.

veins adjoining ihe wound in many cases of amputation, and the
presence of pus in the parenchyma of tiie lung, liver, and brain. But
the absorption of pus by venous trunks opening on the surface of a
wound wus a pure hypothesis, Tliut venous capillaries are abJe Uj
absorb liquid substances in contact with them is incontestable, but \i
was difficult to make a cautious physiologist admit that divided,
gaping vessels could do the same. Again, by admitting for the forma-
tion of metastatic abscesses the transfer and the deposit of pus in the
internal organs, they placed themselves in contradiction with the iatiU,
since we have a first and even a second stage in which is found, at
the place which would afterwards be occupied by the abscess, an in-
filtration first of blood and then of plastic material. Nevertheless the
theory was accepted, and reigned for a certain number of years under
the name, which you still hear from the mouth of old physicians, uf
purulent absorption.

2d. Theory of PhlehUk. — Dance' taught, and after him Cruveilhier,
Blandin, and F. Eerard developed, another doctrine, in which the
mixture of pus with the blood still appeared as the inaiu explanation
of the disease, but in which phlebitis was made U> play a great part,
as well in the origin of the pus as in the mode of formation of the
metastatic abscesBcs, Dance had discovered in many puerperal women
this fact, recognized afterwards by surgeons in patients who had
undergone amputation, that the venous trunks of the affected parts,
we may say of the wound, were inflamed and suppurating, and that
the pus often extended lo the neighbourhood of a collateral branoli
opening into the aflwted vein. He inferred that the siream of blood
through this collateral might carry away the pus and pour it into the
general circulation. This pus once in the blood would mingle with
it so thoroughly that it could not afterwards be separated from it.
But it would alter it and reader it so irritating that its passage into
certain capillaries, notably those of the viscera, would lead to new
phlebitea (capillary phlebitis) characterized first by the formation of
small clots, and then by the production of pus which would be the
consequence of the irritation caused by the clots.

Although based upon an undeniable fact, the presence of pus in
the veins, yet this theory was frequently found in contradiction with
the facts, and still left a large part to hypothesis. It first supposed
that in every case the veins corresponding to the wound which was
the starting point of the infection had suppurated ; but Darcet, tiedil-
lot, Teaaier, in works which I sliall presently mention, had been led
to modify Dance's and Blanditi's theory, because they had often
sought for pus in the veins without finding it.

I myself, when examining the bodies of patients who had died of
purulent infection, have often carefully dissected the veins of the
region of the injury or operation, within which the disease must cer-
tainly have had its origin, and I have fouml no pus in them. The
theory of phlebitis supposed moreover that this pus found an easy

.labitu en Q^ueral (AichivvG GenCraltis

P0RULBST INFECTION OB PT-EMIA.

jBssage into tlie neighbouring veins. But Tessier' proved clearly thafeJ
'le inflamed veins contained biood clota as well as pus, and that iii,

lany cases these clots lay above the pus, and were so adherent that

ley must have opposed its migration.

Finally, this theory would lead us to expect that the pus glohuleSi

^Ihat had paaaed into the blood could be detected in it by the aid of

the microscope. But examination of the blood of pyieinic patients

has shown that it does not contain more than the usual number of

leucocytes.

As for a capillary phlebitis preceding the formation of the metas-
tatic abacesses, that might possibly be admitted for the lungs, but it>
could not for the liver, the synovial membranes, or the musciilnr in..,
teratices, in which we do not find the piirident collections preceded byl
those blood clots which may be attributed to coagulation in the!
veinnles.

To these serious objections it must be added that the theory
phlebitis had the disadvantage of leading to no prophylactic measurt
Admitting that the disease is engendered by pus in the veins, we eaa'
suggest nothing to prevent the production of this result. Surgeons
could only bow and wait. You will see thai the final theory of which'
I have yet to speak, the one which I have long accepted, purely hypo-
thetical as it still may be, has the advantage of inviting and justifying
prophylactic measures the efficaciousness of which has been proved
by experience,

8d. Doctrine of Seplictemia. — Tt was after the objections made b;^
Teasier to the doctrine of phlebitis as the starting point of puruleni
infection, that the first works appeared in France upon this theory,'
which in the beginning received no special name, and to which wel
have since given that of sepliaemia. This theory explains purulent!
infection by the absorption and introduction into the blood of invisi-
ble and intangible putrid or septic miiterials produced by the blond,
serosity, gangrenous tis.sues, and mortified inflammatory exudations
which are found on the surface of wounds during the early weeks of
suppuration and sometimes later.

This theory, generally attributed, even by French authors, to German
physicians, had in reality its origin among us. To assure youraelvaa
of this fact you have only to follow the chronological sequence of
works publislied upon this subject.

Darcet is the first, so far as I know, who, without using the word
seplicmmin, formulated in France the doctrine in question. But hia
work was baaed upon facts and ideas which were related not to puru-
lent infection itself, but to other diseases which are closely allied to
it by their nature and gravity, and which, in fact, belong to the great'
morbid group now called septiciBrnia.

Thus Gaspard and Magendie published, in 1823,' a series of experi-
ments showing that the injection of putrid matter, notably of pua
nnd urine, into the veins of animals produced artificial fevers aimili
to putrid and typhoid fevers.

'f thati^H
at iitl^H

. that.^H

bulesi^^l

244: TRAUMATIC FEVER. PYEMIA, AND SEPTICEMIA

Eouillaiid also, in a very remarkable article upon phlebitie, puh-
liabed in 1825,' pointed out the frequent coinuidenue in human beings
of phlebitis with symptoms analogous to ihoae of putrid or typhoid
fever. He recalled Gaspard and Magendie'a experiraenta, and spoka
of pua formed by phlebitis and poured into the general circulatioo.
But on the one hand he occupied himself especially with putrefied pus
as the cause of the trouble, and aaaimilaled it to the putrid mutter
used by Ga-spard and Magendie, ami, on the other hand, he explained
the development of fevers by the passage of deleterious substances
into the blood, without paying special attention to the one which has
since been known as purulent infection.

Thus, too, Bonnet of Lyons, in 1837,' studying the chaoges of pus
due to contact with the air, showed that iu conaequeace of the habitual
presence of sulphur in pua the usual products of its decomposition
were sulphuretted hydrogen and sutphydrate of ammonia, and that
these essentially deleterious substnnces, when once formed, could be
absorbed by wounds and give rise to febrile com plications, to which
he gave no special name.

Lastly, Prof. B^rard also, long before the publication of bis masterly
article in the Diclionnaire in 30 volumes,^ taught that a distinction
was to be made between purulent infection, which he attributed, as
did Dance and Blandin, to the passitge of pus into the blood, and
another variety of poisoning which occurred later, and which was
due to the passage into the blood of the materials formed by the
decompo.sition of the pus, which had been so well studied by Bonnet.
B^rard gave the name of putrid infection to this malady, similar in its
origin to purnlent infection, but dift'ering from it by the later period
of its development, by its symptoms, its anatomical lesions, and its
prognosis. If P. Biirurd had applied the same opinion to the develop-
ment of traumatic fever, and if he had employed the expression
septiofflrnia to indicate these various morbid conditions due to the
absorption of deleterious substances diftering themselves according to
the moment of their formation, he would have completed the edifice
whose entire construction has been very improperly attributed to our
German contemporaries.

The ground had thus been prepared by previous works when Felix
Darcet,' leaving the rather vague generalities in which Gaspard, Ma-
gendie, and Mona. Bouillaud had remained, and leaving aside also P.
Bcrard's putrid infection, came to give an explanation, analogous to
that of the others, of purulent infection properly so called.

This author reported a aeries of experiments which showed, accord-
ing to him, that the decomposition of pus in contact with the air gave
rise to two products: the one a subtile intangible poison, which, after
having been absorbed, and thus distributed over the entire economy,
would produce the phenomena of fever; the other less toxic, solid,

> Bouilland, Sur \e Pltl6bitH (Rrtuv M^iliiuilu. 192!);.

' bnnnul, M^uiaire sur In Cuinpasition ot I'AbdorptiaD du Pus (Qaielte U6diottls,
1837. p. 593).
3 P. Bfirard, Diolioiinaire Ae MSiieofiie, artiole Pus, 1842.
* DnroHl, ReoliBroliHHsaries AliuiaMaltiplaa atsnrleR Aooidenta qu' Ainiuela Fl:^;^^

PPEULENT INFECTION OK PYEMIA,

I divided into very fine particles, which eould pass through vessels of
a certain size, but were promptly stopped in the capillaries, especially
; in those of the lunga, and might, by acting as irritatiog foreign bodies
thei'e, lead to the formation of metastatie absceasaa.

I am glad to recall this opinion, for you see in it the germ of the
one uttered by Virchow fifteen years afterwards. The latter author
attributes metastatic abscesses to the arrest in the pulmonary capilla-
ries of small so-called embolic clots coming from the veins of the
injured region. According to Darcet, also, fibrinous particles were
arrested in the capillaries, but be supposed tbem to come from the pus
and not from the blood.

After Darcet, M. Sedillot' wrote that purulent infection was not due
simply to the passage of pus as such into the blood, but to the passage
of putrid substances absorbed from the surface of a. wound, and
resulting from the ulcerative and gangrenous destruction of the parts
in which suppuration was impending. According to this eminent

I .Burgeon, in short, the deleterious principles which cause the disease
Come especially from the mortified and sloughing portion, which we
always find upon wounds at the beginning of suppuration.
Then M. AtphonseGn^rin,"in 1847, likewise opposed Dance's theory,
and sought to prove the correctness of the opinion which he after-
wards defended warmly before the Academic de Mi^decine in 1871,'
that purulent infection is due to the passage into the blood of special
■ miasms scattered through the air, which fall upon wounds and are
absorbed through thein. According to M. A. Gu^rin the miasms in
question are found especially in hospital wards, in those in which
cases of purulent infection are already present, and in ali crowded^.T'
badly ventilated places, and thus he explains the greater frequency o
the disease in hospitals than in private practice, in the city than ii
the country.

Notice in passing, that this theory, without being strictly proved,
had at least the advantage of causing the ado|)tion of the great pro-
phylactic measure, free ventilation and renewal of the air about those
who have been wounded or operated upoi

Similar ideas, so far at least as the explanation of the disease by a
sort of poisoning is concerned, were maintained by Jules Gu^riu*and^
Maisonneuve, who, admitting like Darcet and Sedillot the decomposi-''
tion of the pus, blood, and mortified tissues on the surface of a wound,
explained purulent infection by the absorption of these deleterious
iSubstances, whose passage into the blood may take place with the pus,
but also without it.

I myself had been familiar for several years with these ideas. The
autopsies of a certain number of wounded and amputated whom it
was my lot to treat in one of the services of St. Louis Hospital, ia^

■ 1. Sedillot, Oa rinfaotian Paraleuta (Aiinalaa da
kl843, toiiia Tii. p. 126), &nd De I'lufMclinu Puriile

• Alph. Qufirin, TUSaea de Piria, 1B47.
■ Alpli. Guerin, Diaoanrs sar I'luruotion Puraleute (Bull, de rAcadua

Rfftne, 1871, toma xxxtI. pp. 202 and 307).

* J. tiuSria, Bull, da I'Auad. do )U4«^1W«1&T1, tome xxxvi, p. mz.

ica

ed,
re-
vise

34:6 TRAUMATIC FBVER. PYEMIA, AND SEPTICEMIA.

charge of which T had been filnced nt the beginning of my surgical
career, after the bloody outbreak in June, 1848, proved to me ihat
suppurative phlebitis wna absent iniioh more oftea in patients afl'ecied
with piinileiit infeetinn than the works of Dance, Cruveilhier, and P,
B^rard had led me to believe. And by suppurative phlebitis I mean
that of tlie large veins which run through the soft piirts of a limb that
has been amputated, or has received a comminated fracture. On ex-
amining the bones of those who had succumbed after multiple sup-
purations of the skeleton and soft parts, I found, it is true, suppuration
and putrid changes in the medullary substance, and I at first supposed
that, according to the theory wiirmly taught by Blandin, the pus,
iuatead of forming in tlie large veins just mentioned, had started in
those of the marrow, and that thus a phlebitis of the bones had been
the starting point of the purulent infection.

Seeking next upon the cadaver for the proof of this phlebitis of the
hones, I found in many cases the nutrient vein filled with pus. But
in many others I found nothing of the kind. I was unable to isolate
the veinuleaof the marrow itself sufBciently to determine the presence
of the pus which would demonstrate the existence of phlebitis.

I was, therefore, forced to recognize that if phlebitis of the bones
may in certain cases, and when phlebitis of the large veins of the soft
parts is absent, be invoked as the cause of purulent infection it cannot
be demonstrated anatomically.

But while making these searches, I was struck with the profound
alteration of the medullary substance, in which I vainly .sought for
suppurating veins, I saw that it was gangrenous, mixed with altered
blood and decomposed pus, and that it had the odour of putrefaction.
I then began to ask myself if these products of putrid osteo- myelitis
of which I have already spoken to you (page lil4) might not pass
into the circulation without being carried there by the pus.

For such a thing to be possible, it was necessary that the surface of
the wound and that of the bone should be capable of absorptiou.
Bonnet of Lyons' had admitted the first. The teachings of physiology
also justified the belief. Nevertheless, I studied this question by ex-
periments upon men and living animals. In 1954 and 1855, 1 placed
a great many times pads soaked with a ten per cent, solution of the
iodide of potassium upon wounds at different periods of their course,
and half an hour or an hour afterwards I easily detected the iodine
in the urine or salivte by the aid of starch, the mixture of which with
these liquids gave the blue colour of the iodide of starch. I have
already spoken lo you (page 228) of these experimeota, and of another
which I made upon dogs three different times, and which consisted in
forcing into the medullary canal of the femur, by means of a syringe
and a tube provided with a screw, which I fixed in one of the walla
-of this canal, a little of the same solution of iodine. A faucet placed
at one of the ends of the tube enabled me to retain the liquid, and to
keep it from spreading over the soft parts. In eacli case I ibund the

line in the animal's urineabout three-quarters of an hour afterwards.

PURULENT INFECTION OH PYEMIA.

24S

'In my opinion, therefore, it could not be doubted tbat tlie surface of
la wound and that of the medullary canal were capable of absorption.
^A new demonstration of tlia former haa likewise been furnished by
M. Demarquay in a paper rend before the Acadi^mie de MiSdecine iu
1867,' and upon which I made a report.^

Having acquired these two facts, the presence of putrid substances
,iipon wounds and in the medullary canal, and the possibility of
^absorption, I continued to examine the large veins in the bodies of
'those who died of purulent infection, and the interior of the bones
iwhioh had been attacked by acute suppuration, and I felt more and
.more convinced that it was not simply the passage of the pus of sup-
Jiurating veins into the blood which occasioned the infection in ques-
ttinn, that if this passage took place consecutively to phlebitis, the pus
of the veins probably swept along with itself putrid matter, coming
■cither from the wound or from the bone, and that 6nany the passage
-of these putrid substances might take place and causa the affection
■without the veins sharing in the suppuration, and without the pua
jfierving as vehicle. I developed this opinion in my work upon V-
flhaped fractures*

But I did not stop at purulent infection. In the same article, as I
<have already told you (see page 229), I did not hesitate to assign a
poisoning as the cause of grave traumatic fever; and as that ocuurs
■especially in cases in which the large bones are the seat of suppura-
tive inflammation together with a concomitant wound, I thought that
jthe poison in such a case also was formed out of the medullary sub-
stance exposed to the air, and seriously inflamed in consequence of
the accident. I further expressed the opinion that other febrile
surgical affections, "such for example as that seen after the opening of
an abscess fay congestion,''* alter incisions and operations upon the
urethra, after the opening of hematoceles with thickened walls, that
which characterizes erysipelas, and lastly, that called puerperal fevei'"
can be explained by an analogous poisoniug.

You see, gentlemen, I also lacked only the word septiaemia to sui
,iip and make intelligible my conception of the pathogeny of purulent
i^infection, as well as of the other forms of febrile aft'eotiona that may
iieomplicate wounds at the different stages of their evolution. I admit
jthat I was wrong in not making use of this word which haa the
'Advantage of expressing very well the general doctrine I adopted, but
i did not think of it.

Since that time I have not failed to expound in my pathological
_ind clinical lectures these ideas of the method of development of
[atraumatic fever and purulent ii.fection, and sorne years afterwards I

V with satisfaction the confirmation by German authors, by means

experiments upon auimals, of the views which I had uttered r^-

lat

> Deraarquay, De rAbsorptiaii aar las PlaJes (Bnll. de 1' A:>aiianile lie M£ileoine, Pm
)a<!-()T, touiM Kxzii. p. 157, and Uemolrva da I'Auttd. de UM. lB6T-(iS, '
.. 424.)
' Gosaalin, Ball, de I'Aoad. da UiA. 18SB-18UT, tome xxsii. p. 930.

2iS TRAUMATIC PBVBR, PYEMIA, AND SEPTICEMIA.

garding traumatic fever, and those which my compatriota and myself
had held upon purulent infection properly ao-oalled. These authors
did not quote ua, and seamed to think that tliey were the sole inventors
of the doctrine of septicsemia. They fell into this error, c5oubt!e.«s,
because they were not familiar with what had been done here. The
thing which asttmishea me, that against which I protested before the
Acadi5mie de M^decine,' the 27th of March, 1871, is the readiness with
which French anthora, forgetting in their turn what has been done
amongst us to establish this doctrine, have not feared to give it the
name of German doctrine. According to what T have just told you
the Germans did not invent this doctrine, they only strengtheued it,
fortified it, and popularized it. Neither did they invent the word
septicfemia, which for more than twenty years has had a place in the
nomenclature of our learned oompatriot Piorry,

And now, gentlemen, after all the researches I have made, after
the fresh study of the subject into which 1 was necessarily led by
the long discussion in the Academie de M6decine, I adopt and I oifer
you the (bllowing theory in explanation of purulent infection. This
grave disease is composed mainly of two things: —

1st. A set of clinical symptoms which we can classify under the
name of fever.

2d. Multiple anatomical lesions the chief of which are the so-called
metastatic abscesses.

Let U3 examine these two points successively.

1st. I consider the fever as the result of a poisoning by toxic
materials formed on the surface and especially in the deep parts of
wounds.

These toxic materials are often transported by the large veins,
within which they are mixed either with pus or with blood. I do
not believe that simple non-putrid pus causes the disease in question.
If the pus passes into the blood it produces it only because it is
mingled with deleterious substances formed either by the decompo-
sition of the pus within a vein which has become the seat of a putrid
suppurative phlebitis, or by the decomposition of other parts of the
wound, the products of this decomposition being capable of causing
suppuration by their passage into the large veins, at the same time
that they infect the organism. In my opinion thus there are several
gates by which the toxic substances which cause the infection can
enter: first the large veins containing altered pus and communicat-
ing with the general circulation by some collateral branch, the flow
through which bus not been obstructed by a clot; next, the veinulea
which absorb and transport putrid materials without their being
arrested in the large veins and mixed there with pus or coagulated
blood; and lastly the lymphatioa which may likewise convey these
poisons without themselves receiving any injury or any irritation
from contact with them which might make them suppurate as the
veins do. For, notice it well, gentlemen, the lymphatics and the
veins act in three ways in the development of purulent infection:

PUECLBNT INFECTION OR PYEMIA, 249 |

^botnetimea they are merely passages and undergo no change, some-'i
^^^mes their internal surface inflames and suppurates in conaeqiienoB
of the contact of the poisons which pass over it ; sometimes they take
on suppurative inflammation before this paasaae and as a result of
their participation in the inflammatory process whioh invades all the
constituent parts of the solution of continuity, and the pus which has
formed within them becoming putrid furnishes the deleterious mate^
rial which the collateral branchea then carry into the general circa-^
lation. Thus we explain all the facts which occur since we have
L/ecognized the relatiou between phlebitis and purulent infection, to
wit: sometimes the coincidence of the suppurative phlebitis with
^ia disease, sometimes, and more rarely, the coincidence of suppura-
Kve lymphangitis, sometimes, on the contrary, the absence of pus in
^ese same vessels, or at least in those of them which anatomical
finveatigation allows us to trace and to observe.

Now, whence came the poisons and how are they formed ? T have
told you that possibly they may come from pus previously formed
within the veins and the lymphatics, and changed either by contact
with the air or by the unwholesome nature of the morbid process
which gave rise to it. But they often come from the suppurating
wound and are carried into the lymphatic and venous trunks by the
capillary vessels which have absorbed them on its surface. Their
origin then is either in the decomposition of the pus, or of the blood,
or of the suppurating and gangrenous medullary substance, or of the
gangrenous and broken-down soft parts, or several of these together.
This decomposition is still the consequence either of contact with the
air, or of the malignity of the suppurative inflammation; but the
conditions in which the disease is most frequently developed compel
us to attribute most influence to the air. For you know, gentlemen,
that the suppurating wounds which are moat often complicated with
pyaemia are the deep ones, that is, they are those in which, nolwith-'
standing the surgeon's eflbrts, the pus is retained between the muscular,
layers, in which, furthermore, the sloughs of the aponeuroses, tendon^ ■

tnd muscles are alow to be eliminated, and remain so long as their
sparatioa has not taken place in the depths of the wound.
This forced sojourn of poorly vitalized or quite dead tissues in the
lidst of soft parts which at the same time admit the air, leads to the
decay — that is, a putrid or septic decomposition similar to putrefac-
tion in the open air— of the soft parts which are entirely separated
from the organism. You see how much more favourably constituted
ua this respect superficial wounds are; the pus flows away easily, the
Mflchars are thin and quiokly eliminated, and, if necessary, we can.
Hburselves remove them. The prolonged sojourn which is favourabls ■
to decay and to the formation of toxic substances does not e.xist here.
And let us not forget that among the deep wounds the ones wiiich
give rise most often to this affection are those at the bottom of which
large bones take part in the suppuration.

In fact, before the development of suppurative inflammation, and
during the first few days which follow it, something analogous to
what we see upon the soft parts takes place within the bones. In

250 TRAUMATIC FBVER, PYEMIA, AND SKPTIC^m:

the former there is nofiuppuration without a certnin amount of altera-
tion of the blood remaining on the surface of the wound, ami without
the production of eschars and of exudationa likewise destined to mor-
lifii:ation and elimination. When the wound ia deep these pheno-
mena appear throughout its whole extent, consequently within tlie
medullary canal, and probably also in the canaliuuli of the bune.
Suppuration is preceded and accompanieci within tliese canals hy
gangrene and exudations whose products are altered by contact with
the airwhich has penetrated and become confined there.

Putrid and toxic produeta, therefore, are formed in every suppu-
rating wound. But when the wound is superficial they are leas abun-
dant and remain for a shorter time, and consequently are leas liable
to he absorbed than when it is deep, or where a hrolteu or divided
bone lying at its bottom takes part in the suppuration. In this latter
case there are moreover the toxic products formed by the medullary
fat, products which may be dangerous in themselves, but which ure
rendered especially so by their prolonged retention in an open cavity.
This, I think, explains why purulent infection is much more common
when suppuration of the soft parts is accompanied by suppuration oE
a bone than when it is not ao accompanied.

In short, gentlemen, according to the theory which I propound to
you the dangerous alteration of the blood which produces the dis-
ease is not due exclusively to pus ; it is due to numerous putrid aub- j
stances, of which some have their origin in the pus, and the others ia
the decomposed blood, the eschars, and the exudative detritus of the
putrid and gangrenous marrow.

But here three obji;ciions are made. 1 do not hesitate to meet and
answer them.

They aay to me: You attribute a r6Ie to gangrene and to the de-
tritus which it furnishes for absorption, and yet you are the first to
recognize, and you often teach, that destruction of soft parts (normal
tissues and tumours) by caustics which produce eschars is almost never
followed by purulent infection. That is true, but notice the differ-
ences; when we use caustics their first effect is to destroy the lym-
phatics and bloodvessels, and to cause their obliteration by the coagu-
lation of the blood and lymph, and by primitive adhesion by means
of plastic lymph ; the eschar ia produced immediately, or at least is
coinpleted very rapidly, and when decomposition sets in, when sup-
puration and elimination begin, all communication haa long since
ceased between the mortified part and the adjoining living tissue.
Moreover there is no blood to putrefy, no exudation deprived of vi-
tality, no serosity liable to decomposition ; in a word, there are none
of the many sources of poison which we find in wounJa. The eschars
of the latter form much more slowly ; during several days tliey have
still enough vitality to carry on exchanges with the living parts, and
to communicate to them the putrid substances they have produced;
the adjoining vessels are not yet obliterated, they too share in the
unhealthy inUammation which invades the entire solution of cotiti-
Duily ; and, lastly, there are, together with the eschars, those olbor

PtTBETI-BNT INFBOTION OE PTJltflA.

261^

liquid and fatty prodacls which suffer change by conliict with the a
and which are not found uijon parta destr(jyed rapiiJly by caLiaiics,

The second objection ia this: You regard as one of the factora the'
suppuration of the bone and especially of the naarrow, and yet yo'
show ua every day patients suftering with suppurative osteitis, in the']
aftdctions generally known as caries and neci-osis, who are not attacked ■]
by purulent infection. They live months or years with thissuppura-'
tion of the bones and die from other diseases. That ia all very true;'
but notice again tliat it is not the suppuration alone that I regard a
a factor, but also the d&'<tructions and mortiGcations that accompany
its beginning, and which you do not have when the osteitis advancea
slowly towards suppuration and when the latter is not carried on in
contact with the air. When these ossifluent abscesses of caries and
necrosis open iind the air penetrates into the cavity, it finds pus and'1
nothing but pus there. It may atill cause this pus to putrefy. WheB.[|
the cavity is deep arid extensive, aa in abaceaa by congestion, thia
putrefaction may become the cause of another variety of 8eptica;mia,4
that known by the names of putrid infection, hecticity, hectic feveri»l
But the air does not meet, as it does in wounds, with those miitiple*
elements of which I have spoken, blood, fat, mortified exudationsjfl
now, it is this multiplicity of elements which gives rise to the septiO'jl
products capable of engendering pyfemin. In short, a great distino-W
tion must be drawn, in this respect, between acute suppurativi
osteitis and chronic suppurative osteitis. The first produces, together')
with pua, putrid substances which the latter does not.

Furthermore, we must draw a distinction between the acute sup-
purative osteitis which is set up without preliminary solution of con-'
tiniiity, and that which occurs after such solution of continuity. The ,
former sometimes causes purulent infection, as I told you when speak-
ing of the spontaneous acute osteitis of adolescents; but the iJItter is
much more liable to do so, though not always and inevitably.

Remember that the essential condition of the production of purulent
infection is that the acute suppurative osteo- myelitis should become
putrid. Now this does not always happen, and, as I have often told |
you, our treatment should be directed towards, and should sometimes
succeed in, preventing it.

The third objection is as follows: You apeak to ua of poisons
coming from the blfcod, from aeroaities, exndaliona, pus, eschars, and
mortified marrow; but now which one of all these furnishes the real
poison of purulent infection ? And furthermore, when you explain
traumatic fever you still take your poisons from the same sources.
Are they then the same in both cases? On thia point, gentlemen, I I
do not conceal my eTobarrasament and my doubts. If I could isolate' j
the organic poisons of a wounded patient, if I could watch their for-^l
niation, T would tell you exactly where they arise, whether they result; f
from the union of molecules coming from all the altered parts of ihei-'
wound, or whether they come mainly from certain ones of them. I
would tell you alao in what the pathogeny of traumatio fever differs
from that of purulent infection. But none of these points can be
made out by me. 1 see an important effect produced — a dangerous

252 TRAUMATIC FKVEH, PYEMIA, AND SEPTICEMIA.

fever, I see, as a plausible explanation of this effect, putrid anb-
Btaneea and tlieir jibsorjition. Bull can go no fiirther, and that la wliy
I told you at the beginning tliat, whatever we mii^ht do, we alwava
brous;ht up in this research against something that was iaexpHcable
and hypothetical.

I presume that the poison of purulent infection has a complex
origin, and that the molecules furnished bj the putrescent marrow of
the bones play a large part in it. I presume that the poison formed
during the first few days, that which occasions traumatic fever, is differ-
ent from that which is developed later and which gives rise to puru-
lent infection. I recognize that according as the symptoms of the
presence of the former havu been more marked, so is the latter more
likely to be produced. I understand how di-stinguished surgeons,
M. Billroth, in Germany, M. Verneuil, in France, seeing so often
grave traumatic fever precede and in some sort prepare the way for
purulent infection, have been led to think that these two affections
are but one and the same, and that pyramia is the second degree of a
aepticiBmia of which traumatic fever is the first. But upon this point
we are all unable to prove anything. We are obliged to confine our
selves to suppositions, to ask indulgence for our theory in considep&-
tion of the excellent points it furuishea for prophylaxis as I shall irjr
to sliow you in another lecture.

2d. Let us now see how the multiple suppurations, often internal,
sometimes external, the so-called metastatic abscesses, can be ex-
plained by the theory of septicemia.

Here again I shall be compelled to admit that a rigorous explana-
tion ia nearly impossible.

I have already spoken of the original theory, the deposit in all
parts of the body of pus taken up or absorbed from the surface of the
woundf and you know the reasons why we could not adopt it.

The first was that it ia diffiuult to believe in an absorption suffi-
ciently abundant to supply the numerous and sometimes large colleu-
tions which we find, especially those which form within the synovial
and serous cavities.

Next, the theory being true, the microscope ought to show large
quantitie.^ of leucocytes in the blood of pysemic patients; but, aa I
told you, the blood contains only the usual number. Aud finally,
since the facts have led us to the opinion that it is net pus but invisible
and intangible poisons which cause the infection, we cannot admit
that the pus is all formed in the blood and has only to be deposited
in the organs,

I spoke also of the suppurative capillary phlebitis admitted by
Dance and Cruveilhier as a means in the formation of metastatic ab-
scesses. These authors thought that the blood, by admixture with
pus, became irritant, phlogogenic, as it ia termed to-day, and that,
passing into the venous. capillaries of certain viscera, eapecially those
of the liver and lung, it produced in them a suppurative iudnm-
mation similar to that caused by mercury and other foreign bodies
when injected into the veins, as in Cruveilhier'a and Darcet's experi-
menta. ~

BTIOLOQT OF 8DBQI0AL SKPTICJIMIA.

25S

II should be willing to accept thia interpretation if the metastatioj
abscess developeil everywhere in the same manner, that is, if it pasae
everywhere through a first stage characterized by the black spot re*
Bemhling an eccliymosis, and which might possibly be attributed 1
tbe stoppage of clots in the inflamed veins. But this first stage ii

»8een only in the lungs, sometimes in the spleen. We dj not 6
in the liver, where the abscess seems to begin by a yellow spot whicB
U not blood, and which is not pua either. Still leas do we find it ii
the serous and synovial membranes aiid the muscular interstices
where the pus forms very rapidly without being preceded by aa^
appreciable I

The same objections ean be made to Darcet's fibrinous and VirJ
chow's sanguineous embolus. You may possibly accept it for thS
lung, but you need another explanation for the liver, the serous aua
synovial membranes, and the muscular interstices.

»In presence of these varieties in formation, as shown by anatomical
investigation, there is only one thing to be said, and that is that s
Boon as the blood has become altered by its infection, and the feveM
has declared itself, the whole economy becomes apt for snppurationj
So long as there is no poisoning, the suppuration remains local, an(Tr
all the efforts of the organism are turned to the process of repair, i
which the regular secretion of pus is an essential condition,
as poisoning has occurred, the pyogenic aptitude is disarranged; is
becomes generalized, and the organism makes pus, at the expense a
the altered blood, everywhere except at the point where it first prM
pared to make it.

LECTURE XXXI.

ETIOLOGY OF SURGICAL SEPTICiEMIA.

ml etiology of trHlliniitio fuser atiil puruliint iafactiau, lat. Local or anrntoml-
2d. Individual Ksiieral onases — InttaoLiEs of nge, Bai, temperament,
alcobnllo habits, moral emotions, phyH Ion I snffitring. 3i1. Almosplierio general
atloD of the uIf b; urowdiug — PosBitil^ abaorptiao of inlsKina by the.
woand and by tke reapiratorj organs. J

Gentlemen: I gave you in a former lecture my op'nion upon the'l

' mode of development of purulent infection. But that lesson would

remain sterile if I did not try to show you how, on the one aide, the

tangible causes of the disease accord with this pathogeny ; and how,

on the other, the knowledge which we have of the relations between ,

Lihe etiology and the pathogeny leads to therapeutical and prophy^

^actic notions. But, as a close connection exists between traumntig

fever and purultmt infection, and since the prophylaotio maasun

TRAUMATIC FEVBSB,

emplnyed against tbe one are equally suited for the other, I prefer
to unite tliem under the name of seplicmmia, or, as M. Jules
Guarin bus styled it, of purulent intoxicalion, and to apply to both
the cnnsiderationfi which I have to present you.

I warn you, moreover, that these considerations apply not only to
gunshot fractures but to all wounds and operations which expose to

Eliohgy. — Purulent poisoning (and by this term it is understood
that we mean that whiuh t^tarts from a wound in which suppuration
is impending, aa well as from one whiuh has begun to suppurate)
recognizes three kinds of cimsea: loyal or anatomical causes, indi-
vidual general causes, and atmospherical general causes. Let us see
how these causes accord with the pathogeny I laid before you.

lat. Local or Anotomical G"uses. — We linow them; they maybe
summed upas follows: formation upon the wound of putrid sub-
stances or septic poisons, and possible absorption either before or
after the establishment of the suppuration. We know that deep
wounds, especially those in which the bones inRame and take on
putrid osteo- myelitis, are more likely than any others to cause it.

Do not lose sight of the fact, that, if decomposition of the pua is one
of the sources of the formation of the poisons, it is not the only one,
— it is not even the most important. In fact, if putrefaction does not
occur upon the surface and in the deep parts of the wound during
the 6rst few days, and if the pus alone appears there, poisoning is rare.
Ne.\t, when the wound has passed this period of twenty or twenty-five
days, during which putrid substances are formed upon and remain
in it, and when there is no lunger anything but pua, poisoning again
becomes more diflicult and rarer. If then I have retained the name
of purulent infection, it is in order to conform to general usage, and
also because the Ibrmalion of the poisons coincides with the begin-
ning of the formation of the pus. Do not forget, on the other hand,
that this formation of putrid substances upon wounds is the conse-
quence of a process of destruction which follows the traumatism and
precedes the definitive establishment of the process of repair. Uer-
tainly it would be much better if things took place differently; but
the fact is none the less true, that a large wound, before it becomes
lined with a red and freely suppurating membrane which is the indi-
cation of properly advancing repair, covers itseif with sloughs more
or less deep, useless exudations, and blood clots, and tliat al! these
products exposed to the air may there undergo putrid changes.

This preliminary destruction is more or less marked. It is accom-
panied by a more or less considerable putrefaction. There lies the
explanation of the differences which we see in practice, certain sub-
jects being much more exposed to putrefaction and its consequences
than others. The study of the general causes will also show us the
same thing,

2d. Indlviduol General Causes. — It has been correctly said that
persona of every age, of both sexes, of every temperament may be
attacked by gepticasnua. But with respect to frequency there are
individual variations wbji(!j;-,we must recoa;njze ifl_^raoU(^i

r ETIOLOGY OF SURGICAL SEPTICEMIA. 255 ^H

Let US first consititir age. ^H

Beyond all question, cliildreti may have both kinds of poisoning, ^^M
But trauniatiu fever, violent enough to be fatal, is quite exception^ ^^M
among ihem, and it is undeniable that of one hundred children whu.^^|
have Bufiered amputation or have received gunshot fraetures, the ^^M
number attauked by purulent infection ia much leas thiin is the case
with adults. I v^ish 1 could indicate this proportion by figures, but
I cannot, since it has been my lot to treat only a few children. I
nake this et-.itement in accordance with the general impression left
ry my personal experience, limited though it may be, and with theJ
esults furnished rne by surgeons of hospitals for children. Thial
liminished frequency can be easily understood. The constitution of-B
& child has not been exhausted by the general causes just mentionedtj
bodily fatigue, moral impressions, alcoholisms, syphilis; furthermore J
the marrow of their bones is less abundant, less fatty, more vascular, j
less liable to putrefy ; lastly the vitality of all their tissues is grealer.J
There is then less tendency to destruction, and consequently fewer J
ibstaeles to tiie process of repair than in the adult; it is more diiH- I
lult for the phlebitis and osteo-myelitia to take on a putrid character.'!
Let us now consider sex. I

It seems to me that women are rather less exposed than men to I
mrulent infection. This is both ihe result of a general imprestioa I
,nd of my owa statistics. In the paper which I read before theJ
Medical Congress of 18H7,' I reported eight cases of amputation ofJ
the thigh or leg, in women, with three deaths, two of which were by I
purulent infection and one by hecticity. I had had these two caseai
of purulent infection out of eight operations, a proportion of twenty- I
five per cent. The same operations performed upon men have given 1
me, on the contrary, the proportion of about forty per cent, of the *
same aS'eetion. Again, I recall the casea of women treated by me '
a(\er the civil war in 1871, for gunshot wounds involving important
parts of the skeleton. They are not numerous: a fracture of the
ihoulder,'a fracture of the humerus, two fractures of the leg, a frac-
.nre of the superior and inferior maxilla. None of thecn hud purulent J
fifectiou, none died, and yet all had at first acute and then chn>nia J
iuppurative osteo- myelitis. But the osteo-myelitis was not putrid, oP ■
was so to so slight a degree that poisoning did not follow. Three oSt
tbsm had traumatic fever, but it was moderate and, as happens iri ■
such eases, did not lead to the fever of pyemia. In this respect therel
is a distinction to be made between traumaticerysipelas and purulent!
infection in women. They sufler more frequently from the first and^
less frequently from the second than men do. The explanation is toil
he fouud in causes analogous to those favouring childhood. AhM
though a woman is more impressionable, her constitution is ordi-v
narily less broken down by bodily toil, irregular hours, and alcoholism^ I
than a man's is, and tliis is especially true of the men of the working!
^elasses in large cities, those who supply most of our hospital cases. ■
■ As for letiiperameut, 1 know nothing in particular, and I am furcedl

^- 1 MM da CongrM MSdlol InlBinatlDuat da ISST, p. 2Si. J

256 TRAUMATIC FKVKB, PYEMIA., AND SEPTICEMIA.

to recognize that the most robust, as well as the mnst delicate, may
he affected in the same proportion as soon as the other causes begia
to act.

The facts which came to our ootioe after our late battles convinced
me that fatigue resulting from long marches and loss of sleep, alco-
holic habits, exposure to cold prolonged over several hours, especially
at night, after receipt of the injury predispose, as essentially debili-
tating causes, to the spread of the preliminary destructions which are
the main source of the poisoning.

Moral emotions — those repultingfrom the discouragement produced
by defeat, those caused by the prospect of a long illness, of a perma-
nent infirmity, by the fear of death, a fear necessarily increased in a
hospital ward by the sight of the death of neighbours or comrades
wounded on the same day — these emotions are incidental, though not
predisposing causes of poisoning. In order that repair shall go on
regularly, and that the putVefaetion of the preliminary work of de-
struction shall remain limited, it is necessary for the patient to eat,
sleep, and digest. This he does not do, or he does badly, if his mind
is preoccupied and saddened, as it often is after severe injuries.

I have spoken elsewhere' of the influence of physical sufferings,
the long duration, or too frequent repetition of which, produces simi-
lar results.

3d. Atmospheric General Causes. — These are certainly the onea
which exert most influence.

Tessier, when opposing Dance's doctrine of the consequences of
suppurative phlebitis, was the first to show clearly that purulent in-
fection was due mainly to the crowding of the wards of a hospital
with sick and wounded, and that this crowding did not explain the
development of venous suppuration and the consequent passage of
pus into the blood, and that it certainly acted in another way.

Since then hospital surgeons in large cities have learned from
those of their confreres who practise in the country and small towns,
and who treat their wounded at home or in hospitals containing few
patients, that purulent infection and grave traumatic fever are very
rare among them. When Messrs. Topinard^ and Leon Lefort,' after
their visits to England, taught us that surgical poisonings were less
frequent in the London than in the Paris hospitals, they indicated as
principal causes of this difl'erence: 1-st, the fact that the English
wards were less crowded than the French; 2d, the more complete
renewal of the air in the wards by the frequent opening of the win-
dows as well as by an efficient system of ventilation,

Siiil later American surgeons confirmed these views by the statis-
tics of the wounds and operations whioh the war of the rebelliou
gave them the opportunity of observing upon a large scale.

While in France, at the time when Malgaigne published his first
and important work upon the results of capital operations in the

' Actes du Cougr^a MMioal Intaruatlonal de 1867, Pnris, lSii3.
" Topiiiard, TliflssK d« Paris, 18U0, Na. 38.

> L. Lafgrt, Du la Reseotlnii de In Hunulia dims lei Caa Ae CoKal^ie et de Flaies
par ariues il tt>a (Men. d« I'Aoad. de M^cuma}, Igiil, tomu xxv. p. 445.

■ ETIOLOGY OF SOEGICAL SEPTICEMIA. 257'

Paris hospitals, the proporlioo of deaths, almost all of thetn due to
purulent infection, was from 70 to 75 per cent., in these American
statistics the proportion was only 30 to 35 per cent, for the same ope-
rations. The difference was explained by the two cireumHtancea
that in America the patients' beds were widely separated from one
another, and, above all, were placed in tenta far from other habita-
tions and almost constantly open.

The general impression wbieh resnltad from these works, — and
which, for my part, I aided to create in France by giving the greatest
publicity to M. Lefort's comparative studies upon the English and
French hospitals in my report to the Aead^mie,' and in the long discus-
Bion upon nosocomial hygiene which followed, — the general impres-
sion, I repeat, was that vitiation of the air by crowding in the principal
cause of surgical poisonings.

Iq what does this vitiation consist? Is it due simply to the various
emanations arising from the presence of to'o many people in a limited
space where the air is not sufficiently renewed ? Is it due to special
miasms arising in wards occupied by wounded persons from suppu-
rating wounds, or to specific miasms coming from those already
affected by surgical poisons? Does it occur in all these ways at once?
Thus far our experience has not enabled us to pronounce upon this
subject. Everybody admits and ought to admit, for clinical experience
proves it moat positively, that the crowding of patients vitiates the
air, and that this vitiation engenders septicaemia in patients who have
deep suppurating wounds. But no one can say positively in what ^
this vitiation consists.

And here another question naturally arises. The air being vitiated
by these miasmatic emanations, by what way do they penetrate into
the organism of the wounded patients, and how do they act in pro-
ducing surgical poisoning? i

As for the penetration, we have to choose between two routes; that
of the wound, and that of the respiratory organs, unless we admit ,
that the poison enters by both.

Our learned colleague, M. Alphonse Gu^rin, did not hesitate to
choose the first. He distinctly maintains the opinion that wounds,
being able to absorb, introduce into the general circulation the miasma '
which the vitiated atmosphere deposits upon them; the first cooclu-
sion that he drew was one confirming Tessier'a views, that we should
prevent, above all, the vitiation of the air by crowding. Afterwards,
in 1871, he adopted a second one, the necessity of the occlusive appa-
ratuses of which I shall soon speak.

This theory, which has had the merit of giving a great impulse to
the search for and application of prophylactic measures, is certainly
very attractive. But I have made and still make this objection to it : ^
all wounds are capable of absorption, the superficial as well as the
deep ones, the ossifluent as well as those which do not communicate
with the bones, and yet they do not all absorb those atmospherical
miasms which are supposed to be able to develop the infection. You .

' Bulletin de I'Aoailemie de MMtwlne, 1861-32, tome zxzrji. p. 53. j

]
I

know that palienta with superficial woonils are less exposed to it thsn
those with deep wounds, auii those with deep wouniis, and without
osteo-myelilis, much lesa than those with deep wounds and osteo-mye-
litis. It is in vain that M. Alphonse Gu^rin replies that deep and
ossifluent wounds have much larger surfaces of absorption. The
answer to that is in these enormous solutions of continuity seen in
burns and in certain accidental wounds which pass through all their
phases without becoming the occasion of purulent infection. More-
over, if the infection were caused by the absorption of atmospherical
miasms by the wound, why should this absorption take place during
the first twenty-five days and not afterwards? The wounds of which
we are speaking last for forty, sixty, ninety days. During all this
time they are able to absorb, during all this time they are in contact
with vitiated air, yet the further we get from their beginning the lesa
is infection to be feared.

I do not deny, if you will, the absorption by the wound of niiasraB
contained in the air. But it is impossible for me, for the reasons I
have already given, to believe that this absorption is sufficient by
itself to give rise to grave traumatic fever and purulent infection.
We can, moreover, explain the local action of the vitiated air other-
wise than by the direct penetration of the miasms into the circulation.
I have told you that the mortifications and putrid changes in wounds
were due to two main causes: a certain quality of the inflammation
which depends upon the idiosyncrasy of the patient, and the contact
of the air. Now it is possible that air vitiated by these invisible
miasms in hospital wards exerts its decomposing influence more easily
than perfectly pure air does. Still, I do not hide from you that this
is only a presumption, and that I can in no way prove the proposition.

Let us now examine the other route, that of the respiration. If
the vitiated air enters the lungs at each inspiration, it is allowable to
believe that the deleterious miasma contained in it penetrate into the
blood, and that this penetration aftects the health in a way that ia in-
jurious to the progress of a wound. Two serious objections present
themselves here: First, this same vitiated air is breathed by other
patients who have no wounds. They are not attacked by any fever,
and their health does not seem to be affected in any way by this
hygienic condition which is so unfavourable to tho.se with serious
wounds. Then all those who have wounds do not become poisoned,
notwithstanding that they all breathe the same air. How is it then
that ibis vitiated air, if it acts through the respiratory organs, pro-
duces upon some what it does not produce upon others?

There is, it is true, a new difBculty in the explanation. But it
seems to me capable of removal by the ideas which I propounded
upon the conditions of local putridity necessary to the development
of surgical poisonings. In order that these putrid substances should
not form it is necessary, as I have already told you, that the patient's
health should be good, and that all his functions should be regularly
performed. It is especially needful that the blood should be properly
transformed and purified, and that no foreign element should change
it. This condition is necessarily afiected by respiration in |^

tPTIOMUlA..

phere charged with miasnig. If the passage of these latter into th^i
blood does not sensibly aQ'ect the health of those who have no opea"
wounds, or have only superficial oaes, yet I can understand that
might BO afteot those who have to undergo deep suppuration, am
especially that of osteo-myelitia. In fact it is at the expense of the
blood that the exudations necessary for the formation of a good pyO'
genie membrane are made. If this blood is not sufficiently pure it
produces unhealthy membranes, which mortify; it exeites this exces-
sive inflammatory process, which leads to the partial death, and ulti-
mately to the putrid decomposition of the tissues covering the solulioa
of continuity. In a word, vitiation of the blood by imperfect biema-
tosis acts upon the wound which is about to suppurate in the same
way as vitiation caused by fatigue, loss of sleep, moral emotions,
alooholism, and prolonged exposure to cold ; and you understand that
when all or many of these causes of vitiation act at the same time,
the patient has but a slight chance of escaping a grievous poisoning.
Happily there are organisms which resist everything, and we see from
time to time in our wards patients who, notwittistanding the existence
of unfavourable conditions, escape suppuration, or, in whom, if it
irs, it does not assume the putrid character,
sum up my views upon the influence of unfavourable atmos-
rberical conditions in saying that if this influence is local in a certain
measure, which I cannot prove, it is also general, in the sense that it
gives the blood, through the respiratory organs, certain qualities which
predispose it to furnish upon the wound and in the medullary canal
products which putrefy easily.

And I express my views upon the general etiology of traumatic
poisonings in saying that they depend upon a series of individual and
atmospherical causes, each of which acting alone may produce them,
but which in all probability unite and act simultaneously; and it is
not unlikely that poisons varying in nature and amount may result
from the complex intervention, and in different proportions, of all
these causes. Thus may, perhaps, be explained both the differences
which we see in the more or less rapid course of regular traumatic
fever and purulent infection, and those unusual forms of fever which
do not appear early enough to belong to primitive septicemia, and
which, on the other hynd, not presenting the ordinary symptoms of
purulent infection, ought to be considered as intermediary or incom-
plete septicemias, to which the cHnic has as yet given no special

of I

iTi'

3 th9i^H
opeu'^^l
lat it^H

f the^l

1
I

TBAUKATIC 7BVSR, FTAUtA, AND SHPTIC^UIA.

LEGTURJ& XXXIT.

TKEATMENT AND PROPHTLAXIS OF SUEGICAL SEPTICAEMIA.

CaratiTB treatmenl of septicffimiai almost nil — Prapbylaotic treatment verj D9«fnl—
laolalion of the wonuilefl in pure air frequently renewed — Different dresaing!:
nuiting, aoBlnsive, infrequent, simple, and repeated— Preference giFen to thu
infrequitnt and occlnEive cotton batting dressings.

Gentlemen: I have little to say on the subject of the curatire
treatment of surgical poisonings.

In tranmatic fever, as I have told you, it is limited to diluent or
tonic drinks, a laxative, a few injections, and a dose of opium at
night. But we must not deceive ourselves; these measures have but
little effect and are almost anmeaning.

In purulent infection the tincture of aconite has been refiommendeH,
and I have often prescribed it in a potion or in the tisane, in the
dose of two grammes the first day, three grammes the second, and
four grammes the following days'

I have also given the sulphate of quinine in moderate doses, aay
seventy-five centigrammes or a gramme daily, or even in a large
dose, as M, Alphonse Guerin advises, say a gramme and a half the
first day, and two grammes on the following days, and although our
colleague has had some success with this, I have seen it, like the
preceding one, fail in most cases.

It is true that I saw one of our patients in May, 1871, with a sup-
purating gunshot fracture of the right humerus, recover from a puru-
lent infection after having taken for a fortnight the dailv dose of two
grammes, and even during the last few days of two and a half
grammes of sulphate of quinine. But, on the other hand, I saw a
wounded man at the Hopital St. Louis, in 1848, and two at La Piti^,
in 1865 and 1866, get well without the help of any medicine.

In short, some fortunate subjects after having shown all the symp-
toms, especially the repeated chills, of purulent infection, get well.
But this has not happened often enough to prove the real efQcacious-
ness of any drug. The few who have recovered after treatment with
one or another of them, would probably have done just as well with-
out them.

I do not, however, wish to discourage you, and to advise you to
remain inactive spectators of the contest carried on by the organism
against the poisons. I advise you to give sulphate of quinine not-
withstanding my doubts of its value, to give with it from thirty to
sixty grammes (3i-ij) of brandy daily, pure or mixed, in a potion
with from two to four grammes of the extract of cinchona. I wish

atanili radicii (IJJ^^

TREATMENT OP SCRGIOAL SKPTIC-SMIA. 261." I

fMly to warn you that recovery is very rare, that the real curative |
■ treatment ia yet to be found, and that consequently we must first I
I turn our attention to prophylactic measures. T

[ Well, the theory which I have developed before you }\bs, above all |
I'Others, the advantage of opening the way to every prophylactic eo-^ |
Edeavour, and that is why I have adopted it, uot withstanding the
■"^hypothetical nature of so much of it.

T I have told you, that, according to the unanimous opinion of alt

licontemporary surgeons, air vitiatSi by crowding is one of the main .

•causes of the poisonings, and especially of purulent infection, Yo* I

■fiee at once the consequences. When you have a patient whoso I

^wound expoaea him to septicaemia, and especially when, in all proba- J

bility, acute suppurativa osteo-myelitia may set in, you should put I

him in a room which is not crowded and in whieh the air can bo- 1

changed. -M

Of late years you have heard small hospitals recommended, small' J

wards, and, so far as possible, the erection of hospitals outside of thcnl

large cities. As applied indiscriminately to all patients, these prenf

cautions are exaggerated and useless, ]

Speaking only of patients with surgical affections — those who have
no wounds and those whose wounds or ulcers are superficial are notex-
posed in ordinary hospitals to the diseases we are now considering. It
ia always well to avoid crowding, to have, for example, about 40 cubic
metres of air for each bed, to have means of ventilation, to change
the aip by opening the windows, to have separate rooms for the deliri-
ous and those with erysipelas. On these conditions a hospital may
»be established in a large city and receive without objection 500 or ^M
ISOO patients. H

But these conditions are not suFGcient for those whose wounda. ^H

tili
K|o(

He(

expose them to traumatic poisoning, nor are they sufficient for puer-
peml women whose uterine wounds expose them in the same way.

For such patients, in hospital, large isolated rooms with good ven-
tilation are needed, each to contain only three or four persons. These
looms may, if necessary, be in an ordinary building, but the hygienic
inditions are best realized by a tent, large enough lor four or six
placed in a large open space, such as our Paris Administration
has already furnished to the Necker, St, Louis, and Cochin hospitals,
and such as I have for several years asked for at La Charite, where
the small size of the courtyards and gardens renders the plan difficult
of accomplishment. And this leads me to say, in passing, to those of
'ou who will be called some day to advise upon the construction oC J
fospitals, that it is necessary above all things to have open spacw,1
irge enough to contain, under conditions of proper aeration, warmeefel
ints or huts for patients whom you know to be threatened with a
lUlrefaction and all its consequences.
Of course, if the patient is in a private house every effort shoul^^
bo made to give him a large room facing to the east or south, with atfl
least one large window, and, if the season is suitable, an open fire
heating sufficiently to allow the windows lo be opened occasionally
without chilling the room,

If the topographical conditions of tha h^i^.'jvvA q\ q'v N>ia\iSiw.ti 4

262 TRAUMATIC FEVER, PY-KMIA, AN'D SBPTIC^K:

not allow these indications to be properly and permanentlj met, you
must try to tlo it temporarily at Ifjist by carryinsr the patient from ode
place to another. At the St. Louis ami LariboisiSre hospitals in Paris,
for example, I have seen patients aiiftering from serious wounija and
amputations placed in tents during the day and brought back to the
wards at night. In case there are no courtyards or gardens, the bal-
conies can be made use of in the same way, as they are large enough
to hold several beds, and allow the patients to be brought into the
open air, when the weather is suitable, without the inconveniences
incidental to carrying them. Balconies, however, are lacking in most
of our hospitals. They are an improvement which you may find it
well to remember.

In private practice, if there is no courtyard or garden to which the
patient can be taken during the day, if moreover the season is not
suitable, or if it is too cold for the windows to be opened long enough
to effect a renewal of the air, the patient should at least be moved from
one room to another in his bed, ss I advise and practise in the treat-
ment of erysipelas.' When the change has been made, the windows
of the room which the patient has juat quitted are left open for three
or four hours, and then the fire is lighted and the room warmed before
he is brought back.

But if the conditions are such that the patient can be isolated
neither permanently nor temporarily, if his room cannot be changed,
and if, as is too often the case in our hospitals, he has to remain con-
stantly in a more or leas crowded ward, our only resource is to secura
the renewal of the air, as far as it is possible, by keeping the windows
open whenever the weather permits. When the weather is warm the
problem is solved easily enough, but when it is cold it is much more
difficult and we have to contend against all sorts of opposition. A
draught of fresh air is often disagreeable, the patients, the orderlies,
the nurses themselves are slightly incommoded by it, infer that it is
dangerous, and hasten to close the window. In this respect La Piti^
Hospital was better than the others in which I have served. One of
the windows in the male ward was so arranged that it could be left
open all day anJ often part of the night without troubling any one.
The nurses and servants were not disobedient, and I obtained very
good results, better than I obtained elsewhere, which I mentioned in
my paper read before the Medical Congress of 1807.

Apropos of ventilation, you often hear managers and architecta
praise artificial ventilators, like those which have been constructed at
Beaujon and LariboisiSre hospitals, into the details of which it would
be useless to enter here. The principle of these systems is very good,
for its object ia to renew the air without chilling the room. But the
results obtained in the surgical and lying-in wards of these two hos-
pitals have proved that they are not sufficient to prevent traumatic
poisoning. It may be that, well arranged as they are, these ventila-
tors renew the air only very imperfectly. They establish only very

} da Meilaoine el de Ckiiargia Pratiqaefl,

ETBGATMENT OF SURQICAL SEPTICEMIA. 263^^H

TOW an(J litniterl currenta instead of the broad ones produced by^^H
iti windows unci fireplaces that draw properly. And then tfaese'^^
apparatuses rarely work well. They depend upon a fire which has
to be fed constantly, and which, either by negligence or lack of fuel
or for any other caose, is allowed to go out. Then the ventilation
stops, I am far from proscribing ventilators absolutely; but I con-
sider them insufficient for the object which we now seek, and their
use, though it may be advantageous for the mass of patients, Joes not
relieve us from the necessity of using for those now under conaidera'
tion the measures of isolation and aeration which I have mentioned.

Dressings. — Surgeons have always sought, but especially during the
last sixty years, for modes of dressing large wounds which would
protect their patients from the complications which now occupy us.

The ideas which guided them varied, and were gradually modified
by those which were advanced as to the origin of these complications.
Not wishing to speak of ali kinds of dressings I shall mention only
those whose principal aim has been to prevent traumatic fever and
purulent infection, and I shall try to show how their mode of action
accords with the pathogeny I expounded before you. From this

Ptandpoint I shall examine successively: uniting dressings, ivfrequent
'ressings, dressings by aspiration or pneumatic occlusion, occlusive dress-
igs, disin/ecling dressings, and finally daily, simple, and pavitess dressings.
Uniting dressings. — By this name I designate those which keep ^^
the edges of the wound near together and, so far as possible, in con-^^|
tact for five or six days by means of strips of diachylon plaster, or of^^^^f
linen dipped in collodion, or of interrupted or quilled sutures. Their ^^M
object is to obtain what is called immediate union, that is, cicatrization
of the solution of continuity without suppuration and by prompt
transformation into cicatricial tissue of the plastic lymph or blastema
which is poured out after the first twenty-four hours on the surface
[And between the lips of the wound. You see at once how, so far as
iiutrefaetion and septiciemia are concerned, tliis kind of dressing
would act. It would prevent suppurative inSammation, and with it
"[he whole train of local symptoms, at the head of which we placed
he formation of eschars and the decomposition in contact with the air
f ail the organic parts deprived of vitality.
Nothing could be better than such a result; but can it be easily
Ibbtained? is it often obtained in practice? and, in case of failure^
Sfcave the measures taken to procure it any disadvantages?

Kotice first, gentlemen, that immediate union is impossible in many
cases; in those, for example, in which the integunaents have suffered
a loss of substance ; in those in which although there has been no loss
of substance the edges are so widely separated that they cannot be
brought together ; and finally in those of contused and gunshot wounds
with such bruising of the edges that mortification and suppuration:
must take place. We can examine it then with reference only to thosa:
cases in which it is possible, and that is maiuly those in which ampa-

tition has been performed.
As for those, I do not hesitate to tell you that immediate cicatriza-
on is very rarely obtained. I have aeea it, and so have olhei^|

264 TBADMATIO FEVSK, PYEMIA, AND SEPTICEMIA.

surfieons, succeeii in children, in whom, moreover, the attempt it
UDSucceBsrul haa not the disadvantages of which I ithall presently
speak. But I have seen it succeed very rarely in adults, and all my
collaaguea at Paris have had the same experience. A few years ago
I heard it said, and I have also read in Serr^'s Tmile de la Reuidon Im-
midiafe,' that they succeeded more often in the south of France, and
especially at Montpellier. But I doubt if this assertion has been
justified by a sufficient number of facta, for now I hear the contrary
asserted, that attempts to obtain immediate union upon adults have
no greater success in the south than in the centre and north of France.

I believe myself then justified in saying that in the immense ma-
jority of eases suppuration is not prevented by this mode of treatment,
and that in your practice hereafter you should use it only if the
experience of your predecessors and yourselves has shown that the
locality where you praetiue is exceptional in this respect, and that ia
it wounds, when their edges are brought together, generally heal
without suppurating.

Understand, too, how difficult it ia to obtain completely the result
sought for by dressings of this kind. In an amputation wound you
have to distinguish two things, the iutegumental edge and the bottom
of the wound. The edges are easily kept in contact by the means of
reunion, and have a simple structure which allows prompt agglutina-
tion without suppuration. But the bottom, that part composed of
muscles, tendons, aponeuroses, and bones, cannot be brought together
so exactly.

Even when a flap amputation has been made, there are always
irregularities of the surface which do not allow all the points to be
brought, and especially to be kept, together; how then can we hope
that all these parts differing in vitality will be simultaneously pro-
tected from that which always threatens in the first period of exposed
■wounds, that is, the mortification of some of the tissues over which
the knife has passed. However perfect may be the coaptation of the
edges, is there not reason to fear that a little air may have been im-

firiaoned at the bottom of this wound, and that the blood and the
ymph, when poured out, will be subjected to its decomposing influ-
ence? Clinical observation, gentlemen, has shown these objections
to be well taken. At the beginning of my surgical career I tried,
and saw others try, to get immediate union; this was in consequence
of what Prof, Ph. J. Koux' had told us of the habitual and even
exaggerated use of this practice in the English hospitals, and of the
views which John Bell's* and Jticherand's' works had popularized
among ub; and yet I never saw perfect immediate union without any
suppuration ; ih.at is, in the very exceptional cases in whiuh I got
good results, and in the two children upon whom I had to amputate
at the thigh, there was suppuration at the surface of the wound, the
edges of which had not united immediately, and a little deep suppa-

■ TBEATMENT OF 8DRGICAL SEPTIO^MIA, 265

ration along the ligatures which reached from the bottom oFthe wound
to the surface. This suppuration, however, ceased as soon as the
ligatures came away.

The beat that I saw and obtained, then, was not a complete avoid-
ance of suppuration, but its absence from the bottom of the wound,
especially about the bone, and with this so limited suppurative inflam-
mation, the absence of the febrile phenomena engendered by acute
BUfipurative osteomyelitis.

This result, rarely obtained as it may be, is ao favourable that wo
should have to continue to employ this mode of dressing if it were
not for its disadvantages, which are real and serious when it fails.
Immediate union of a part of the edge, or, if you prefer, of the super-
ficial portions of the wound, takes place. But the deep parts remain
separated, the efi'used blood and serosity have prevented permanent
contact. Air has been inclosed when the dressing was applied, or
enters at those points on the surface where union has failed. In
short, the blood and the liquids decompose and stagnate in the wound.
Their retention causes a painful distension, increases the intensity of
the inflammation, causes it to take on the gangrenous form, and ex-
poses necessarily to absorption of deleterious substances.

For these reasons immediate union, although excellent in principle,
is not now practised; and I repeat that you should have recourse to
it only for children and small wounds in adults. Do not use it for
the large wounds of adults unless you are practising in a country
where wounds rarely tal^e on gangrenous and septicffimic inflamma-i
tion.

Infrequfnl dressings. — Under this name we class dressings with
which, while seeking, if possible, the same end as with the former,
we expect to have suppuration, but we try to avoid the consecjuencea
of the inflammation which precedes and produces it by protecting it
from contact with the air, and by prolonged rest of the limb.

You will find quoted aa being the first, or one of the first, to re-
commend infrequent dressings, a writer of the seventeenth century,
Csesar Magatua, an Italian surgeon who managed to write a very
large folio volume upon this subject.^ This author objected to the
practice of repeatedly forcing into the wounds tents of charpie,
covered with drugs supposed to favour suppuration, growth of the
flesh, and drying of the wound, and which they changed according
to the stage reached by the wound. Magatus also insisted upon the fol-
lowing points: — that in a dressing we must avoid: Ist, The contact of
the air, because it irritates the wound; 2d, Movements, because they
inlerfere with agglutination; 3d, The removal of the pus, which,
according to him, is a topic which favours repair. With this object
in view he recommended that dressings should be simple and rarely
renewed — every three, four, or five days. You know, and I shall
epeak of it presently, that we go further than that, for you have seen
me leave the first dressing of an amputated limb untouched until the
twenty-second day,

' MagstQB, De iatl> luedioaiioue culuarum, Ben vulueriliaa lutt tiaalandifi, Teui-.

1
I

TRAUMATIC FEVEB, PYEMIA, AND BEPTIC^UIA.

We must suppose that Magatua'a practices and precepts remained
unknown to the French surgeons, or that they were forgotten, or thai
if followed they did not give good results; for when Belioste pub-
lished his work at the end of the seventeenth and beginning of the
eighteenth century* he again protested against the practice which still
existed in his time, of uncovering wounds twice each day; and in a
chapter entitled, Why wounds should be dressed infrequenOy, he advised
that dressings should be renewed only every two or three days,
"Repose," he says, "is necessary for all growths. The nitrous parts
of the air alter the natural balm or nutrient juice which ia intended
to act as a glue to reunite the divided parts,"

Afterwards, when the precepts of the English surgeons concerning
immediate union had been formulated conformably to Hunter's ideas
of adhesive inflammation and suppurative inflammation, all those
who adopted this plan of dressing followed the recommend ^''ons of
Magatus and Belioste, for the first part of the treatment at least, and
left the first dressing in place for four days. Then J. D. Larrey'
called for seven, eight, or nine days, and Josse of Amiens* advised
that the first dressing should be removed on the tenth day, and the
subsequent ones only every two or three days.

Up to this time, yon see, they hardly went beyond the tenth day.
MariSchal, in the cases of amputation of the forearm reported by
Sazie,* went twelve days. But at ihe present time, as I have already
told you, M. Aiphonse Gu^rin, taking up again this method which
hitherto had not yielded results good enough to attract surgeons very
strongly, based his action upon the pathogenic theory that purulent
infection ia due to absorption by the wound of miasma carried by the
i air. The conclusion was simple. Wounds must be protected from
this contact by more suitable apparatuses, and this protection must
be provided especially during the first twenty or twenty-five days —
that is, for the period during which septicemia is most to be feared.
Indeed, after its second application, the apparatus should again be
left in place for about the same length of time; and thus the infre-
quent dressing should be continued until the end, or near the end of
cicatrization.

M. Alphonae Gu^rin might have used the apparatuses invented by
Jules GutSrin and Maisonneuve, of which I shall presently speak; but
in the first place he wished to avoid the complications of this special
arrangement; and, secondly, he wished to add a certain amount of
compression to the proposed occlusion, and he justly sought to use
common materials, which the surgeon would readily find everywhere.
His idea then was to use cotton batting, and to dress amputated limbs
with cotton apparatuses, making elastic compression similar to those
used by Burggrinve' in the treatment of white swelling, so that his

< BaltoBla, Chirnrgien d'Hdpital, Paris, ]S98 ; SDOthei' editiou, ITDB.

■ Larrej, Cliiiique Chirurgioale, toma i.

» JosBe, Mfllangoa de CUirnrgiH, 1885.

* 9a.xla, MSmoiresur 1& ReiiuioD luiaieilirite et tit Iev£e tardive da premtar appsreil
dea plates qui BUDoSdeat aux grandus op^^rationa . (Archives Qgutiratea d« M^doujua,
2d sSria, tome it. p. 1S3.)

' BurggrsTa, Lea Apparaila OuatSi, Paris, 1859.

TREATMENT OF SURGICAL SEPTIO^MIi, 267

infrequent dressing is at the same time a cotton occlusive one. To
make it, the author, who publialieci hia method in June, 1871, covers
the wound and the limb for a long distance above when it is a stump
— above and below when it is a wound without amputation — with a
layer at least five inches thick of cotton batting. Over this he rolls
a band very tightly, pressure through the cotton never being sufficient
to arrest the circulation, or even to cause pain. In case of an ampu-
tation ha carefully carries the turns of the band over the ead of the
stump so as to entirely cover the wadding applied over the wound.
When the wound occupies the thigh or arm he carries the dressing aa
high as the upper end of the limb, or even upon the trunk; and when
the injury is of the leg or forearm the cotton is applied at least as
high as the middle of the thigh or arm.

By the application of this apparatus M. Alphonse Gu^rin' expects
to acconiplisb two objects — that of preventing air from reaching the
wound by means of the occlusion, which seems aa if it ought to be
complete, and that of exerting compression along the whole length of
the limb. At the same time that it may diminish the inflammatory
swelling, and perhaps favourably modify ihe phlegmasia, this com-
pression undoubtedly interferes with the circulation in the lymphatics
and superficial veins to such an extent that transport of septic mate-
rials ia at least diminished, if not entirely prevented. M. Gu€rin, as
I have already told you, leaves this dressmg in place for from twenty
to twenty-two days. He modifies it sometimes on the second or
third day by adding another b.^nd if the first seems to be loose, or if
it has become soaked with offensive liquids.

Gentlemen, this kind of dressing ia still too recent for us to pass
final judgment upon it. I do not wish to speak again of its theoreti-
cal basis ; we could not admit that absorption of atmospherical miasma
was the exclusive cause of surgical poisonings. But what of that?
We do admit that the presence of air is objectionable, and that it is
well to shut it oft' from the wound. Does M. Gu^rin'a apparatus
accomplish this object, and if so, does thataufQce to sensibly diminish
the chances of septicasmia ?

I believe that it does shut the air out entirely, and I base this
belief upon two reasons : it seems to me impossible that the air could
penetrate this thick layer of cotton and the band about it, and when
it is carefully applied as high up as I said, the cotton is pressed so
tightly against the skin that the entrance of air at the upper edge of
the dressing seems to me to be equally impossible. Secondly, I was
present at the removal of the first dressing from two of M. Gu^rin'a
patients' and I have myself removed it on th^SLst or 22d day from
seven patients whose limbs I had amputated. I was struck in all theae
cases by the thickneaa and creamy appearance of the pua, the rosy
colour of the wound, and the abfience of fetidness. Certainly if the
air had penetrated to it the pus would have been altered ; it would
, have become tetid and ammoniacal, and the wound would have

■ Alplionse QaErin, DiBoassion aur I'lureatian Faruleote. (Bull, de TAuad. ile
"I. 1S71, toma xxxvl. p. 32&.)

I
I

assumed an unhealthy look. I consider the fact, then, as aellled
beyond question — M, Gu<5]'iii's dressing prevents the approach of air
to the wound.

But is that sufficient to prevent occurrence of tranmatic fever or
pyasmia ? To this I cannot reply so categorically; for while M, Al-
phonse Gu^n'n, as I myself saw, had a very remarkable series of
cures, I have not always been so fortunate.

Of my first series of aix amputations on account of wounds received,
only one patient survived That was a young officer whose forearm
I amputated near its middle, at the Rothschild Hospital, the twenty-
fifth day after gunshot fracture of the carpal and radio carpal artiau-
lations, with burrowing of pus within the sheath of the flexors, and
continuous fever which seemed to be leading to pyaemia. I performed
then a consecutive amputation during prolonged traumatic fever, and
as I found altered pus and a few eschars in the spongy tissue of the
lower ends of the radius and ulna, as, in short, there were signs of
putrid osteomyelitis, I feared that purulent infection might already
have begun without having as yet manifested itself by chills. Happily
this fear was not realized. The fever did not increase after the
operation. It even diminished little by little. The patient suffered
more pain in his stomp than the others did ; be was first carried into
the garden on the twelfth day. When we removed the dressing at
the end of the twenty-first day we found the wound very rosy, covered
with a thick layer of creamy, inodorous pus, which had also soaked
into the superficial layers of the cotton ; the bones were covered with
granulations, the concomitant erythema was not very marked. After
having cleaned the limb welt, I applied another similar dressing,
which was equally well borne for twenty days. At the end of that
time the wound, still rosy and covered with laudable pus, had dimin-
ished to one quarter its original size. I applied a simple dressing of
cerate, and a fortnight aflerwards cicatrization was complete.

The five other patients whose limbs, an arm, forearm, two thighs,
and a leg, had been amputated in June, July, and August, 1871, died.

But of this I have two explanations to ofier. First, in four of these
cases the operation was a consecutive traumatic amputation, and per-
formed a little late, from the twenty-fifth to the thirtieth day afler
the wound was received. The fifth patient, whose forearm waa
amputated, was operated upon rather earlier, but under particularly
serious circumstances. His right hand had been crushed in a print-
ing machine. The injuries were such that a cure was still possible,
and I had, therefore, tried to save the hand. But on the foijrth day
there appeared one of'those sudden, rapid gangrenes which promptly
invade all the tissues and are accompanied by an intense fever, an-
other variety of septictemia by absorption of the putrid substances
which are formed in the neighbourhood of living parts before the
vessels have had time to become obliterated. It is rarely, no matter
what you may do, that death fails to follow this gangrenous septicro-
mia. Nevertheless, as only twenty-four hours had elapsed since the
gangrene began, and in spite of the high fever (pulse 130, temperature
lOS^VI considered it my duty to propose amputation, and it waa

.p.

TSKATUBIfT OF SOBaiCAL BBPTIO^UIA.

wccepted. The fever of infection continued, and, as so often \
"after intense and prolonged traumatic fever, a violent chill, t
of pyaemia, occurred on the sixth or seventh day afier the amputation;
othera followed, and the patient died before the cotton dressing had!
been renewed. I

One of the four others had undergone rather late amputation of the I
thigh for a gunshot wound, involving the synovia! membrane of the \
knee, and followed by suppurative arthritis with rupture of the upper ■'
cul-de-sac and effusion of the pus into the deep cellular tissue of the
thigh between the femur and the quadriceps. I had proposed ampu-
tation on the eighth day, as soon as I had detected the formation and
spread of the deep phlegmon in the thigh with very marked febrile
I movement. The patient had obstinately refused; but about the
i^wentieth day, when the free suppuration of the knee and thigh had
*«xhaiisted him, when eschars had formed over the sacrum, when the
'tniumatio fever of the beginning had been transformed without inter-
ruption into an intense hectic fever, he begged earnestly for the ope-
ration, which then oSered very slight chances of success, I did it,
nevertheless; but the hecticily continued, and the patient succumbed
a fortnight afterwards. J

Finally, in the other three patients suffering from gunshot wounds,!
whose limbs I had not amputated at the beginning because I had*
reason to expect recovery with preservation of them, and because our
primitive and consecutive amputations had yielded only failures here
at La Charil^, an initial chill, apparently indicating pyfemia, had

i occurred. But this chill had not been seen by the medical attendants,
it was rather vaguely described by the nurse and the orderlies, and
as there were some doubts of it, and as, furthermore, the local and
general symptoms showed that life was in danger, I amputated and
Applied the cotton dressing. But the chills promptly recurred and '
purulent infection showed itself distinctly in all three. Death took I
^lace a few days after the operation, and at the autopsies we found 1
Tnetastatie abscesses in the liver and lungs. '

I am convinced that in these five patients the conditions were

onfavourable, and that consequently their death does not jastify a

judgment unfavourable to the dre.'ssing employed. It is evident that

^^^o kind of treatment, however well devised it may be, will always

^^nireserve from death those who have undergone capital operations;

^Kind furthermore that these operations should be performed before the

appearance of pyaemia, and even before traamatie fever has lasted

long enough and been high enough to preface the way for pyjemia.

That will always be one of the great difficulties in practice, for we

constantly find ourselves between two dangers: that of perforrainw

amputation upon patients in whom traumatic fever has not appeared

at all, or only very lightly, and who consequently, if well cared for,

are more likely to recover, but of whom a large number might also

^'recover without amputation ; and that of waiting long enough to be

^klure that the limb cannot be saved, and by thus waiting to allow

^PtaepticEemia to establish a hold which will compromise the success of

^Kbe operation. As I have told you before, gentlemen, ia dealing

270 TRADMATIO FEVBR, PYEMIA, AND BBPTIC^MIA

with this (iiflicult subject we are surrounded by uncertainties;
must allow ouraeivea to be guided by presumptions drawn from the
condition of the injury, the previous health of the patient, and his
hygienic surronndinga. But these are only presumptions, amid
which, while trying to do rightly, we are never certain that we are
doing what is beat.

To return to the infrequent drCBsing, I told you that, as regards
my five cases of amputation at La Charity I bad another explanation
to ofler-

In two of them I had the opportunity to renew the dressing once,
and I showed you that, as in the cases I saw at St. Louia, and as ia
the one which I myself amputated at the Rothschild Hospital, the
wounds on the twenty-first day looked well, the pus was not fetid,
and there were no apparent eschars. At the autopsies I found dif-
fluent pus in the spongy tissue of the bones and in the medullary
canal, but it did not smell badly, and was not mixed with either blood
or sloughs. There was suppurative osteo-rayelitis, but it was not
putrid, and I am convinced that the septicEeraia of which the patient
died occurred before the operation.

Besides, I have a second series of five amputations for pathological
reasons : one of the thigh, three of the leg, one through the tibio-tarsal
articulation ; only one of them, that of the thigh, waa carried, off by
purulent infection, the four others got well.

You saw as well as I that the application and retention of the
cotton dressing were not painful, and that the principal objection to
it in warm weather was that it had an offensive odour. This we found
to be due to the decomposition of organic matter which made its way
gradually to the outer layers of the dressing, where it became exposed
to the air. But this decompo^iition did not extend to the deep layers,
that is, to the neighbourhood of the wound, where the arrival of the
air seemed to me to be impossible. There is one other objection, the
moist erythema which ia often found extending to a certain distance
about the wound, and which is due to the prolonged contact of the
pus with the skin. This is a very slight objection, it can be easily
overcome by means of starch powder, and has no unpleasant conse-
quences.

In short, gentlemen, notwithstanding the failures of which I have
spoken, the results of this infrequent dressing, as I have observed
them both upon M. Gu^rin's patients and my own, justify me in say-
ing to you that it meets more satisfactorily and simply than any other
the indication of withdrawing wounds from contact with the air, that
it also removes one of the causes of the putrid decomposition which
engenders septicteraia, and for these reasons it ought to be employed,

Does this mean that of itself alone it will preserve many patients
from grave traumatic fever and purulent infection?

I do not dare to believe so; for, as 1 have previously told you, the
pathogenic problem is so complex that the removal of one of its causes
cannot lead to a clinical solution which would amount to absolute
preservation. I told you how much influence must be attributed to
hygienic and individual conditions; I believe to day that if patieota

TREATMENT OF SURGICAL SEPTICEMIA. 271!

Eitb woiinda (surgical or accidental) (Pressed as I have described,-^
mained in crowded and badly ventilated wards, many of thenJ
would still have putrid osteo myelitis to a degree BufRcient to lead tO'i
purulent infection. I also believe tliat this dressing cannot prevent i
the conseqaences of previoua alcoholism and of unfavourable moral's
impressions, such as those which follow in most cases of traumatitfT
amputation from the loss of a limb. I

To state it briefly, I accept M. Alphonse Gu^rin's dressing, but iff I

t addition I want the patients to be placed in tents, or in isolated and>l
IBTflU- ventilated rooms. i

\ Dressings by pneumatic occlusion and hy aspiration. — Starting with I
the idea that decomposition of the pus and other liquids of the wound
"by the air is the main cause of the toxic complications, M, Jules Gn6-
riu likewise thought that the main prophylactic indication was to pro-
tect the wounds from contact with the air. With that view he incloses
the part in an impermeable sleeve, to which is attached a tube cora-
inunicatiug with an aspirating pump which does the work of a pneu-
matic apparatus. By means of this a vacuum is procured within the
sleeve, and the wound is withdrawn from contact with and from the
inOuence of the air. By this method, to which he has given the name
oT jmeumaiic occlusion, M.Jules Gu^rin hopes to prevent not only
putrefaction but suppuration also, and to obtain what he calls imme-
diate organization, that is, repair without suppuration, similar to that ■
which takes place iu solutions of continuity without open wound orJ
with the small ones of the subcutaneous method, fl

M. Maisonneuve at about the same time made use of a similar appa- 1
ratua. He did not think of preventing suppuration, and he announced
a different intention, that of removing by aspiration all the liquids
and even the gases which are found upon the solution of continuity,
and thus avoiding the consequences of the absorption which would
doubtless take place if these same liquids should remain upon the
wound. To obtain this result M. Maisonneuve recommended that the
aspiration should be repeated eight or ten times each day, and that
from time to time a little water or carbolic solution should be injected, J
and then removed by the same means. ;■

These two authors have repeatedly published their methods, but!
not the exact proportion of successes obtained in cases of the kind iu
which prophylaxis is most necessary, those in which the patients are
liable to have acute suppurating osteo -myelitis, and above all they
have not told what this proportion was in cases which, while being .
treated in this way, were obliged to remain in the more or leas vitiatedJ

This absence of statistics and the complicated nature of the apps-^
tuses have prevented other surgeons from adopting this method.'
.s for myself, I waited for the publication of favourable results, and I
lis publication not having come I have done nothing about it. Be- J
■Bides, I had other reasons for not using it. It always seemed to m»M
that in order to procure an absolute vacuum about a wound we should'f
have to make very tight constriction over a certain extent of surface,-]
and that this would cause great pain, and perhaps gangrene of thy

272 TRAUMATIC FKVSB, PYEMIA, AND BKPTIC^MIA.

skin. Now, I feared lest these com pi i cat ions, especially the pain,
might compensate fur the advantages of the vacuum, and add a new
cause of poisoning to those which already existed. I said to myself
that, if Julea Gu^rin's and Maisonneuve's patients did not sufter, it was
probably because the compression was not very tight, in which case
the air would enter between the skin and the apparatus, and thus the
intention would not be realized. Let us withhold our final judgment
until a EufBeient number of successes to compel conviction have been
published. While waiting for these let ua use M. Alph, Gu^rin's
infrequent dressing if we wish to withdraw our wounds from contact
with the air. It seems to me to meet the same indication by much
more simple means; and let us not forget that, whatever mode of occlu-
sion is employed, we must still protect the patients from the conse-
quences of vitiated air.

Disinfecting dressings. — If, for one reason or another, ibe previously
mentioned dressings should not be accepted, we could return to an
idea which has preoccupied surgeons for a score of years, that of
dressing large wounds which expose to traumatic poisoning with sub-
stances which have, or are supposed to have, the property of destroy-
ing the miasms or toxic principles produced by the decomposiliou of
organic liquids.

I told you in another connection that chlorine water, alcohol, per-
manganate of potash, and a solution of 1 or 2 per mille of carbolic
acid had been employed for this purpose. You have often seen me
use a mixture of equal parts of alcohol and a solution of carbolic acid
of the strength of one part of the acid to three hundred of water.

I think I may assure you that experience has not shown the efficacy
of these different agents, at least frorn the stand-point which we now
occupy. I do not deny that they have a certain value in superficial
wounds, or in the superficial part of detp ones, either by retarding the
establishment and diminishing the abundance of suppuration, as alco-
hol certainly does, or by exciting the surface of the wound and pro-
voking the formation of granulations, as Labarraque's chloride of soda
does, or by destroying certain of the miasms, although this is not so
clearly demonstrated aa some seem to believe. But what has never
been proved, and what I doubt, is that these agents have the power
of preventing eschars and putrefaction in the deep parts of compound
fractures, and especially in the cavities and cells of the bones. I
admit that they modify the secretion, and, up to a certain point, the
alteration of the liquids, but for the present 1 deny that they prevent
the formation of eschars and putrid matter, and the consequences of the
contact of air with the moi'tified parts; and I formulate my opinion
clearly as to the use of ihese different topics in telling you that they
have the power of accelerating or retarding cicatrization, but they
cannot prevent death by traumatic fever or purulent infection.

You have recently beard recommended a mode of dressing, the value
of which is supposed to be due to the disinfecting action of carbolic
acid used in a certain way, and in stronger doses than formerly. It
is the one called Liaier's dressini/, from the name of the English surgeon
who recommeuded it. It is arranged in the following way: the

TREATMENT OF BDRGICAL SEPTICEMIA

273

wound, which Ijas previously been united by sutures (suppoaing the J
ease to bean amputation), is then covered with lint soaked in strongly i
carbtilized oil (boiled linseed oil 5 parts, solid carbolic acid 1 part). I
That forms the immediate or permanent dressing, that which is toJ
remain in contact with the wound for two or three weeks. Over this I
first layer ia placed a second, consisting of a paste mode of the same J
carbolized oil and Spanish white (suhcarbonate of lime) so mixed a
to have the consistency of putty. This piiste is put between tw
cloths, and ought to overlap the permanent dressing a quarter of aa J
inch on all sides. It ia to be renewed every two or three days,.!
Lastly comes a piece of oil silk entirely covering the rest I should!
add that energetic compression of the stump is previously made witltj
a band of vulcanized rubber.

I ought to point out to you, gentlemen, that while this dressing ■!
may be regarded aa a disinfecting one on account of the use of a con- J
siderabJe quantity of carbolic ai^id, nevertheless it is so arranged aa .
to act in other ways than tliat of disinfection, Thns, there is a per-
manent portion which, if I have properly understood it, dries upon
the surface of the wound, adheres to il, and preserves it from contact A
with the air. The paste, although renewed every two or three days,
also seems to me to prevent the action of the air. And, finally, ther
is the compression, which, aa in M. Alphonse Guerin's dressing, may I
easily diminish the chances of absorption. In short, I see maiuly ia |
this something which recalls the infrequent dressing; and perhaps Mr.
Lister's success, and that of my colleague and friend M. Leon Labb^
Jiere in Paris, may have been due as much to occlusion as to dia*
fection.

The important point, however, is to know if this dressing succeeds.
Upon this we should consult foreign sources of inlormation, English
chiefly, and French ones. I make a distinction between them because
we are especially interested in the cure of the wounded here among
us, under the influence of our atmospherical hygiene and the consti-
tution of our patients. Now, T know that M. Lister's statistics show
fine results, and that thus far there are no French ones. It ia true j
that the dressing has been but little used in France, but stiil it has i
been sometimes, notably by Messrs. Labbd and Cruveilhier. But J
whether because the trials have not been numerous enough, or
cause they have not been as satisfactory as Lister's, nothing has bees j
published.

Here, too, another distinction must be drawn. Lister has succeeded '
chiefly in pathological amputations. In Prance, for the past year,
almost all our amputations have been for traumatic causes. Perhaps
that is the reason of our lack of success. We had to deal not only
with traumatic lesions, brft with men who were fatigued, demoralized,
chilled, fated inevitably to suffer the consequences of the overcrowd-
ing to which the great number of the wounded exposed them. For ]
these reasons few amputations have succeeded, whatever the dressing j
employed.

This question of the influence of dressings is then too recent to h
definitely answered here in France by the facts. Tiie answer will

274 TRAUMATIC FBVBR, PYiEMIA, AND SBPTIOJBMIA.

depend upon future operations perfornned in pathological cases, and
for the traumatisnns which surgery allows us to observe in time of
peace. Until then I confine myself to the two principal prophylactic
measures of which I have spoken: favourable atmospherical condi-
tions, and M. Alphonse Gu^rin's infrequent and occlusive dressing.

Simple and painless daily dressings^ etc. — Remember, gentlemen,
that the cotton dressing has not yet been often used for compound
fractures, especially for those due to gunshot injuries. 1 should
hesitate to recommend it for the latter on account of the need of
watching for, and treating the difTuse phlegmons which are always so
likely to occur during the first few days. Remember, too, that this
kind of treatment, although it has been used, especially after ampu-
tations, is not suitable for all of them. If then for any reason you
are led to use daily dressings, I advise you to make them so simple
that their application and renewal can be made without movement,
and especially without pain. In case of a fracture the limb should
be placed in a wire splint; after an amputation the stump should be
placed upon a slightly raised cushion covered with oil silk. Without
seeking immediate union, you should yet place the edges of the wound
in the most favourable position possible, and should cover them with
two or three compresses wet with a mixture of alcohol and carbolic
acid solution, which can be removed and renewed without giving any
shock to the limb, and without causing pain and exciting the fear of its
daily renewal. I have spoken elsewhere^ of these simple and painless
dressings, and I believe that under favourable atmospherical condi-
tions very good results could be obtained with them.

' M^moire read before the Cougrds Medical, 1867.

PART V.

DISEASES OF TUB ARTICULATIONS.

LECTURE XXXIir.

DIAGNOSIS OF TRADMATIC DISLOCATIONS.

I. OeueritlitiiiB npon tliia diagnosis — Seuroli for defni'mitj aiid abiionnal prominence

L ftiid depreBsioDS. H. Application of tbetsti fjuneralitieB to a dislocalion of Ui9 J

K alioulder — Bearth for tlie sobacromisl depression iind tiie promiuenue foimed by 1

■ the head of tlie bnmerug. HI. Applioation to a dislooation of the elbon bauk-

' wards — Depression below the humerus — Search for the olecranou, intern si J

epitrochlear, and radial proioineuoes — Lateral mobility. IV. Applicatioi

iliao dislocation of the hip — Searcli for tlia head of the (ulnar and ths great J

troohaiiter.

Gentlemen: I. You see from time to time in the wards patient*'!
affected with traumatic dislocatioQS whicli have remained unrecognized A
for a longer or shorter time.

Tn the course of the year two men have been admitted with dislo- I
oations of the shoulder; dating in one from twenty-two days, in tha f
other from two months before. I was able to make the reduction i
the first, but it was impossible in the other.

Liiat year I made with the Jarvis apparatus, modified by Eobert.l
& Culin, an unsuccessful attempt to reduce a dislocation five weeks!
old of the right elbow. The patient had been attended by tvfo phy- ^
sicians who had not recognized the lesion, and who contented them-
eelvea with putting on leeches and poultices.

I have told you of a consultation to which I was called several 1
years ago in a provincial town, for a supposed non consolidated fract I
tare of the neck of the femur, which was a snprapubic dislocatioQ [
unrecognized fur more than six months. Errors of this kind are I
always prejudicial to the patient, for of two things one: either tha J
dinlocation is afterwards recognized and reduced — but only afteta
having occasioned useless pain, and, furthermore, associated with the!
slower and less coniplete re-esiabliahment of function always found iaJ
articulations which have long remained displaced; or else reductionl
has become impossible; the patient has only the resource of a morefl
or less imperfect pseudarthrosis, and finds himself in u condition ofl
impotence or infirmity which he would have escaped if hia surgeoa J
had recognized and treated the dislocation.

The error is sometimes due to insufficient practical inslructioi

276 DISEASES OF THE ARTICOLATIONS.

because the physician during the period of his studies has not suffi-
ciently attended the hospitals, or, if he has attended them, has not
properly noticed what passed, or listened to what was said.

But, it is also due to this, that the subject is more diflBcult than it
seems to be; and to this, that the precepts of our authors relating to
diagnosis are imperfect, and, as it were, lost amid historical and
anatomo-pathological details.

It is to- protect you in the future from these errors that I wish
to day to speak exclusively of diagnosis; and to give you in a few
short generalities the means, applicable to all regions, of recognizing
articular displacements.

For the diagnosis of dislocations, as for that of many other diseases,
one must look for rational and for absolute signs. I pass rapidly over
the first, because they do not constitute pathognomonic means. For
pain and difficulty of movement are found as well in contusions,
sprains, and articular fractures as in dislocations.

It is by seeking for absolute signs that you must try to make your
diagnosis. Now there are only three for the orbicular articulations:
deformity, abnormal prominences, and abnormal depressions. There
are four for the ginglymoid articulations: the three precediijg ones,
and, in addition, abnormal lateral motion. Let us examine a moment
each of these signs and the means of discovering them.

1. Deformity. — It is hardly possible for orbicular surfaces to quit
one another without the form of the region and the general attitude
of the limb, which I consider as part of the form, being thereby sen-
sibly modified. It is by the eyes especially that these modifications
are appreciated. But remember this, your eyes may deceive you
when you look only at the injured limb. To appreciate it exactly
you ought to compare it with the other side, if, as is generally the
case, that one is the seat of no lesion.

But a clearly ascertained deformity is only an aid in most cases,
and it must not be depended upon blindly. For in many disloca-
tions it resembles that which may be occasioned by a fracture. And
then, it is sometimes inappreciable; for example, when the patients
are very fat, or when, several hours having passed since the accident,
a swelling, due either to the infiltration of blood or to inflammation,
has appeared. Try, then, to estimate the deformity rightly, but do
not depend upon it alone to make your diagnosis.

2. Abnormal prominences. — When you suspect a dislocation, think
at once of the direction in which, according to the facts furnished by
your authors, the displacement may have taken place, and seek the
prominences formed by the articular extremities, especially by that
one which, being the most movable, has abandoned the other. You
may at first use your eyes ; but, especially in the enarthroses, you
will rarely be able to clearly see the prominences, the soft parts pre-
vent it. You must then use your fingers, and carry them as deeply
as possible into the regions towards which pathological anatomy
teaches you that the displacement should have occurred. When you
think you have reached an abnormal prominence, do not be satisfied
with the resistance appreciated by the touch ; keep your fingers upon

W DIAGNOSIS OF TRAUMATIC DISLOCATIONS. 277

the proioinent point and make with vour other hand, or by the hands,
of an assistant, raovementa of rotation, adduction, and abduction, in
order lo sea if the proiuinence moves under the hand which examioeB
it. I have often seen thia complementary exploration forgotten. It
is, however, indisdensable, in order to leave no doubt as to the exiat-
ence of an abnormal prominence.

3. Alnormal digressions. — I do not here mean depressions belonging
to that one of the articular surfaces which is more or less hollow, and
which, in consequence ol'lho diaplacemeiit, nnght be felt through the
soft parts. I refer to those which belong to the whole region, and
whiuh result from the void left by the abandonment of the articular
surfaces. Here, again, you should not depend lipon your eyes alone,
for if the abnormal depressions are sometimes seen, very often they
are not, on account of the volume of the soft parts, It is again to
your hands that you must have recourse. Placing them upon the.
points under which, in the norma! condition, you feel more or leaa
deeply a bony resistance, you no longer feel thia resistance when the
dislocation e-^ists, and you do feel a hollow in its place.

4. Lateral movmients. — They have no diagnostic signification in
enarthroses, since articulations of this kind possess normally all poa-
aibla movements. But they have a very great one in a ginglymoid
articulation, like that of the elbow and those of the fingers ; if, then,
by moving the limb outwards and inwards, you 6nd free lateral

■MMovemeuts which do not exist at all, or are very limited, normally,
^Blfaere is presumption of a displacement after rupture of the Uga-
Huents. It is true that a similar mobility exists in certain sprains,
Bibut it is less extensive, and, further, does not coincide with the
abnormal prominences and depressions which must always have beea
found before a diagnosis of dislocation i^ made.

II, ApplioatUm of the general principle/! to the dini/nosis of a disloca-

Mjtion of the shoulder. — We have just admitted a man, 45 years old, who,

^^ving fallen from a ladder yesterday evening, upon his right eihow,

ialt severe pain in the shoulder, and since then has not been able to

) the limb. Let us now consider the explorations which I have

and which are necessary in all cases of thia kind.

amoved the patient's ahirt in order to uoinpare the two deltoid

pVegions. I satislied myself that the patient could not move the

shoulder, but that be could voluntarily (lex and extend the forearm,

wrist, and 6ngers. This last examination is important, for certain

dislocations are complicated by paralysis of the forearm and hand, the

^Jesuit of a concomitant lesion of the median, ulnar, and musculo-

miral nerves. It is important to have recognized this paralysis

kefore reducing the dislocation, in order Ui be very sure that it hits

lot been caused by mancBuvres employed during this operation.

' Furthermore, I made sure that there was no fracture of the clavicle

of the acromion. I then turned to the deformity and the abuormal

Droniinences and depressions.

. 1st. Deformity — I noticed and pointed out to you the following:

lomparing the two upper limbs we saw that the left arm (the u»«

jjured one) descended vertically along the body, touching it at all

278 DISEASBS OF THE A KTICL'L ATIONS,

points. The right Hnn, on the contrary, was abJucted, and the elhow
about three inches from the body. I told the pniient to bring thera
together, but he wua not able to do it. I then tried to brJTig tliem
together myself, but felt a great resistance, and made the patient
flufter. I coalil only make the elbow touch the body after an involun-
tary bending of the latter towards the side corresponding to the
injury, and as soon as I 1st go the limb the position waa reproduced.
This forced position of the limb in abduction is a variety of deformity
which does not exist to so great a degree in all cases of dislocation of
the shoulder, but which has a certain ynlue. For if it should be met
with in a contusion or a fracture you would be able to correct it, flud
recognize chat, once corrected, it waa not reproduced. Here it vos
only apparently corrected, aud reappeared as soon as I abandoned tbe
limb to itself.

You also saw that the shoulder was sensibly lowered, and that the
patient supported his forearm with the other hand. This sign lias no
great diagnostic value, for you find it in all traumatic lesions of this
region.

Finally, comparing the two shoulders, you saw that the injured one
appeared a little less round than tiie other,

2d. Carrying then my right hand into the arrnpit, I felt for the bard
abnormal promineiice which the displaced head of the humerus would
form. I at once felt a prominenoe; the belter to appreciate it, I ex-
amined the left armpit, and recognized that to feel a bony resistance
1 had to carry the hand more than an inch higher than on the right
side, and further, the resistance which 1 felt at tiiia depth was that of
a much smaller surface. Then again, placing my fingers in the arm-
pit of the affected side, I grasped the right elbow with my other band,
and, rotating the arm, fell distinctly the axillary prominence roll under
my fingers ; I even discovered that this prominence was regularly
rounded. For additional security, and to show yon alt the useful
means of exploration, I asked an assistant to execute these movements
of rotation with two hands, and I felt still more distinctly the head of
the humerus roll under my fingers. I further looked to see if there
was a prominence under the clavicle, behind the peetoraiis magnua,
as there is sometimes in the so called sub-pectoral dislocations, but I
found none,

3d. Abnormal depressionj. — I had only one to seek, the sub-acromial
depression resulting from the removal of the head of the humerus
inwards. I have already told you that among the deformities recog-
nized by the eye is a slight flattening of the outer side of the shoulder.
I pressed tirinly with the lingers of my left hand below the acromion,
iind recognized, especially by comparing it with the other side, that I
had to press very deeply before feeling the bone; the sub-acromial
depression, which waa scarcely appreciable by the eye, waa then very
evident to the touch. To be still more certain, I carried the elbow
further outwards, so as to relax the deltoid, and then felt the depres-
sion still more distinctly. I took care also to make the same mauceu-
vre, comparatively, on both sides.

I admit that iu this patient so minute an exploration was not abso-

^K DIAGNOSIS OF TRAUMATIO DISLOCATIONS, '2T^^^

^Bhitely indispensable Tor the diagnosis. But in patients who are Tattel^^H
^R)r more mascular, or in wliom the inflammatory swelling is greater,^^H
all thpsH pxnlnrationa. niJiHo (ifimiuirativfil v on lidf.h si(lnfl. arfi tiRCaHsars'. ^^n

all these explorations, made comparatively on both sides, are necessary,
and you should form the habit of not neglecting any of them, so aa not
to be at fault when you find yourself in the presence of a difficult

Enlightened by these symptoms, I did not hesitate; for tliey are not
found all together either in contusion or fracture of tha upper extre-
mity of the humerus. I therefore admitted the existence of a sub-
coracoid dialocalion, and reduced it by the method of the heel.

But, as the authors have described quite a large number of varietii
of dislocation, you may have been surprised that I did not carry m^
diagnosis further. On this point, gentlemen, I have a firm convictioni
the only important practical distinction among dislocations of thi
shoulder la that which is founded upon the displacement of the hei
of the humerus in front of or behind the glenoid cavity. The di
placement backward is very rare, it is so exceptional that when dis-
location of the shoulder is spoken of, without specifying anything
more, it is always understood to mean anterior, or, if you prefer,
antero-internal dislocation. As to the distinctions established between
the latter, they are perhaps justified by pathological anatomy, but they
have no clinical interest, because, on the one hand, they can never be
rigorously recognized; and, on the other, the diagnosis would in no
way modify the prognosis and treatment.

An antero internal dislocation having been recognized, it shouh
be immediately reduced. Now, with reference to this, there are twi
categories of dislocations; Ist. Those, and they are the most numerous,
which are reduced by simple means, the so-called gentle methods of
Malgaigne; for example, the method of the heel ; that of Mothe, by
elevation ; that of Lacour, by outward rotation followed by adduc-
tion; 2d, Those which resist the gentle methods, and for which we
are obliged to use, after manceuvres of rotation and circumduction,
intended either to bring the head of the humerus into a more favour-
able position or to enlarge the hole in the capsule, forcible methods,
such as horizontal traction with ordinary bauds and from six to ten
assistants, or with India-rubber bunds, or with Jarvis's instrument,
which, however, is better adapted to old dislocations than to recent
ones.

Certainly, if the precise diagnosis of such or such a variety could*
enable us to foresee a difficulty in reduction, and consequently the-
urgency of a forcible method, we should have to try to make the
diagnosis in spite of the difficulties which it presents. But it is not
so. It is not the position of the head a little further outside or a.
little further inside of the coracoid process, or a little nearer to or a.
little further from the clavicle, it is not that it is capped in its abnor-
mal position by the subscapularia or by the pectoralis magnns, after
a more or less considerable rupture of the latter, which make reduc-
tion difficult. This is caused rather by the narrowness and the dia^
position of the tear in the capsule, or by a peculiar resistance of th»
muscles, that is to say, by conditioDs absolutely inappreuiablti by

re-
lb-

lis'^H

10 i

280 DISKASa^ OF THE A RTICCLATIONS.

whicli do not belong to a special variety of dislnoation, and whieli are
found as well in the sab-eoracoid as in the intra-eoracoid nnd aub-
ulavioiiliir, in the sub-scapular as in the snb-peetorsl.

This is whv I prefer the diagnosis, axillary or sub-coracoid dislo-
eation. To this dingnosin ia attached tbe indication of a reductioD
which must not be delayed, because it will be ao much the eaaier sa
the lesion is more rerent. T shall first try one of the gentle methods,
and, if it does not succeed, 1 shall have recourse to one of the forci-
ble OneB,

III. Application of the fjeneml principles to a dislocation of the elhou
hnckwards. — Here, gentlemen, is a woman, -18 years old, quite fet, who
fell the day before yesterday, and does not know whether it was the
hand or the elbow which received the blow. However that may be,
since then ahe has auftered in the left elbow, and has not been able to
move it. She consnlted her physician, who could not determine what
was the trouble, and sent her immediately to us. I made her undress
in order to compare the two arms; and, after having satisfied myself
that there is no fracture, either of the humerus or forearm, I shall
now make with great care, and applying the general principles which
I have formuhited, the necessary explorations to discnver if there is
a dislocation of the elbow backwards. These explorations will lake
place before you all in the amphitheatre, and I remind you once more
how important it is to establish a diagnosis at once, for if there ia a
recent luxation the reduction will be very easy if made at once; and
it wilt ofler greater difficulties the longer we delay.

1st. I firat examine the shape of the two elbows; the only diflerence
is that which proceeds from the increased size ()f the injured one. All
the normal prominences and depressions are effaced; this is doubtless
due to an infiltration of blood, although ihns far there ia no ecchy-
mosis. There is nothing characteristic in the attitude. The forearm
is in a position midway between flexion and extension, and cannot
make any voluntary movement.

From the moment that we find there ia no fracture we may presume
that the swelling ia the result of a dislocation, for it is not so marked
in contusions and sprains. But the presumption is not sulTicient to
justify attempts at reduction. Let us seek then for more certain signs.

2d, I do not see any abnormal prominence, the swelling ia too great,
but I seek for it with my fingers. Grasping the elbow behind with
my right hand, I bring my thumb upon the point where the head of
the radius ought lo be, and press back furcilily the soft parts in order
to fee! the bone I feel something which ia more prominent than the
radius is when in its proper position. Carrying my finger upwards I
think I feel its cup-like depression, but it is not very distinct. Leav-
ing then my thumb upon this prominence, T take the forearm iti the
other hand, and pronate and supinote it; this time there is no doubt,
my thumb ia upon a prominence which turns, and I also feel the upper
depression roll. I make the same raanceuvre on the right side, which
is uninjured, and do not get the same senaalion. I feel the outer part
of the rudius turn, but I do not feel the whole of its upper extremity,
nd especially its cup, move as on the other side.

DIAQNOSIS OF TEACMATIC DISLOCATIONS.

tMy diagnosis is already adTanced, The upper extremity of th^j
adiua is disloi-ated backwards. But is it alone, or ia the ulnar alstM
dislocated 'I The latter is probable, because isolated dislocation oS
the radius is rare in adiilia, and is seen ordinarily in children. Bat
this is only probable. Let us look for the prominence of the olecra^
non, I find it quite easily, and, comparing it with that of the otheM
side, it seems to project backwards, so that the anteroposterior diamet
of this elbow seems longer than that of the other. But we mu
know if this olecranon i? higlier than it should be, and for that I mu
discover its position with reference to the internal condyle. I sei
the latter by pressing away the soft parts which musk it. Havingj!
found it, I leave one of my index fingers upon it, and, placing thd^
other npon the olecranon, I find that it is a little higher than the
condyle. I make the same exploration on the uninjured side, and
recogniKe that triere the Bnger placed upon the olecranon ia a quarter
of an inch lower than the one upon the internal condyle. There is
then no doubt : on the injured side the olecranon ia higher and project^
a little backwards. Finally, feeling for the inferior extremity of thaj
humerus in front, I find that it is more appreciable by the fingi
ihan the one on the opposite side.

3d. I feel below this inferior extremity of the humerus a depression,
that i.s to eav, that in pushing the soft parts baekwards I feel a hollow,
while on the healthy side the same manceuvre is prevented by a re-
flietance which is nothing else than that of the bones of the forearm, j

4th. By the preceding signs my diagnosis is far advanced, but foi4
greater certainty I seek for the lateral mobility which belongs to dis-H
locations of the ginglymoid joints. You see that, fixing the arm with
one hand, I can carry the forearm outwards and inwards in a way
that is entirely abnormal.

No doubt then ia possible : the abnormal prominence of the radius, .
the olecranon, and the end of the humerus; the depression below thi
latter; all this, without crepitalion, indicates a dislocation backward)
of the two hones of the elbow; and you will see that I shall reduct
it at once with great facility, by pressing the anterior portion of theJ
humerus against my knee, and making extension and counter-exten*
sion with my two hands alone. '

The manceuvre has been made. I felt a shock and a cracking'
which I attributed to the return of the articular surfaces. For greater
certainty, and not to allow myself to be deceived by an apparent
reduction, I repeat my former explorations, and find neither the
abnormal prominences nor the depression. The abnormal lateraij
movements siill exist, but are much less marked. It is then evideoftf
that the dislocation is reduced.

I now ask myself if there has not been concomitant fracture of iha '
coronoid process; in which case, if I did not put on a restraining ap-
paratus, the dislocation might be reproduced. To inform myself on
this point, I fix firmly the lower end of the humerus with one hand,
and, seizing with the other the upper portion of the forearm, I seek
to carry it batskwards, that is, in the direction in which the disloca-
tion occurred. But I do not produce any dispiacement, hence I ooOi

e is ^^_!

th^H

;er!i^^
in,

IW,

i»-^^^|

ith ^^
ay

,.U3. ^^

th»i^^H
ird»^^H
luco^^H

the^H
ten^^^l

:ing-^^
ter '

int
he i|

282 DISEASES OF THE ABTICDLATI0N3.

elude that tbe ooronoid proceaa ia not broken, and that a specitl
Apparatus ia not necessary. Poultitiea and, in a few days, the oom-
pressive cotton dressing will be sufficient to cause the swelling lo
disappear, and to bring about resolution of the arthritis, rendered
inevitable by the ruptures which were caused by the displacement

IV. AppUcntion of the general principles lo an iliac dislocation of (he
femur. — The patient who was brought here yesterday eveoingf, and
who is lying in bed No. 33 of ward Sainte Vierge, is a labourer, 81
years old. He was caught yesterday afternoon by a slide of earth
and rubbish, thrown down violently, and buried under the mass.
When taken out he found that he was unable to walk on account of
a severe pain in the right hip.

This morning we found the patient unable to move the right limb,
and the eflbrts which he made to do so renewed his pain, Conae-
qnently he could not raise his heel from the l)ed, and, in thia respect,
resembled patients with fracture of the neck of the femur. As this
latter lesion is much more frequent than dislocation, we thought of it
at first, but serious doubts were awakened by the fact that the limb,
instead of being rotated outwards, was rotated inwards and adducted.
Therefore I had to look for a dislocation.

1st. I first called your attention to the shape and attitude of the
limb. While at rest in his bed the patient cannot make his two legs
perfectly parallel; the leg on the iajured side remains slightly fiexeJ
upon the thigh, and the thigh upon the pelvis. The foot and the
whole limb are turned iuwards, and when I tried to turn them out-
wards with my hands I did not succeed, but only made the patient
suffer.

Notice particularly this first symptom. In certain exceptional
cases fracture of the nei;li of the femur is accompanied by rotation
inwards; but then you are able easily, with one hand, to turn the
limb outwards. Here, on the contrary, that was impossible, I theo
examined the shape of the hip and of the buttocks, and found them
rounder and more prominent than on the other side.

I then measured the length of the two limbs from the anterior
superior spine of the ilium to the tuberosity of the inner condyle of
the femur, and I found nearly an inch of shortening,

2d. Examining then the great trochanter, I found it more prominent
under the skin than it is normally. I then examined its position with
reference to the crest of the ilium. I placed one finger upon the most
prominent point of the eminence and the other on the crest of the ilium,
and I noticed the distance which separated my fingers; I made the
same exploration on the unaffected side, and it seemed to me that the
distance between my fingers was about half an inch greater on this
aide than upon the other, I then turned the patient upon the un-
injured side, and stretched a string from the right antero-superior
spine of the ilium to the most prominent part of the ischion. While
an assistant held the string in this position, I placed my fingers upon
the highest part of the great trochanter, and found that it was more
thim half an inch above the string. On the left, the uninjured side,
the aume iuvestigatiou showed me that the great trochanter was, as it

P8I
ai

tna

I1IAGN03IS. OF TRAUMATIC DISLOCATIONS. 288-

ouglit to be in the normal condition, upon the ilio iachiatic line. Th»^
sign, which we owe to M. N^laton, positively indicates an ascenaion
the great trochanter, and this ascension corresponded with the short-
ening which I had previously found.

I had then to seek the abnormal prominence which the head of the
femur would form in case of dislocation, I sought this prominence
in the groin and near the obturator foramen. J felt sure that I should
not find it in these regions; for if there had been a supra-puhic dis-
location, the rotation of the limb would have been outwards instead
of inwards; and if the dislocation bad been into the obturator fora-
men, there would have been, together with external rotation, coa*
siderable abduction of the limb, and not adduution.

I then placed my hand over the external iliac fosaa and pressed back
as much as possible tlie mass of the gluteal muscles, and it seemed to
me that I felt under them a hard, round prominence. But the sensa-
tion was not very distinct on account of the thickness of the soft
parts. Therefore, keeping my hand in place, I flexed the thigh upon,
the pelvis, and then felt the abnormal prominence a little more dis-
tinctly, I asked an aid to rotate the thigh a few times, and during-
these movements I felt very distinctly the round prominence roll
nnder my hand, and could no longer have any doubt of its existence.

3d. It only remained for me to seek an abnormal depression.
Theoretically, when the head of the femur is displaced outwards, a
hollow ought to be formed in front, over the abandoned cotyloid
cavity. I then pushed back with both hands the soft parts of the
groin, and it certainly seemed to me that I did not find the same re-
iiiBtance as on the other side. But this sign was not very distinct, and
"lad a certain valne only by its coincidence with the abnormal promi-
lence clearly felt in the gluteal region.

To recapitulate, gentlemen: deformity of the hip, adduction and
rotation inwards of the limb, shortening, ascension of the great tro-
chanter, abnormal round prominence under the gluteal muscles, ab-
normal depression in the groin, — all these symptoms, found in a
patient who up to that moment had hail no disease of the hip, are evi-
dent signs of an iliac dislocation, and oblige us to proceed at once to
its reduction.

I shall first try, without anaasthesia, the gentle method recommended
by Despr^s, flexion uf the thigh, and rotation of the limb outwards
by the hands of an aid, who will get upon the bed in order that he
may, without too much fatigue, combine a certain extension with the
lents of flexion and roiation. One or more aids will fix the
while I myself, standing on the outer side of the limb, will
_iress with the palm of my hand the great trochanter and the whole
Upper portion of the femur inwards.

if I do not succeed, I shall try, still without anaistbesia, a forcible
method, extension and counter-extension by means of straps, aud by
at least six aids to make extension, and four to make counter-exten-
man. In case a first attempt should not succeed, I would try again
Wler having anesthetized the patient with chloroform. Vou know
Kat I have reason to fear the eflecls of ansasthesia in dialooatiooa.

I
I

284 DISEASES OF THE ARTICULATIONS.

That is why I do not employ it at first, and why I only use it after
one or two unsuccessful attempts at reduction without it.
(The reduction was easily obtained by Despr&'s method.)

LECTURE XXXIV.

TRAUMATIC ARTHRITIS OF THE KNEE.

I. Penetrating wound by a piece of glass — Imminent suppuration avoided by the
occlusive and compressive cotton dressing — Two varieties of traumatic arthritis :
one after wounds, the other without wound. II. Subacute traumatic arthritis
after a contusion. III. Subacute traumatic arthritis after a sprain — Reasons
for not fearing an articular suppuration — Congestive form — Possible termina-
tion by simple chronic arthritis or dry arthritis — Therapeutical indications.

Gentlemen : I. Penetrating wound, — A young man, nineteen years
old, wa.^ admitted into the wards two weeks ago, after having been
wounded by falling on a piece of glass. He had on the inner side of
the right knee a wound about half an inch long, with edges quite
smooth and gaping. The accident was quite recent when the patient
was brought here during the morning visit. We found upon the
skin about the wound a reddish liquid which had the viscid consis-
tency of synovia, and, like it, was sticky. We had to think that this
was synovia mixed with a certain quantity of blood. Further, pass-
ing a probe very carefully into the wound, I made it enter deeply
enough to leave no doubt about its being in the articular cavity. The
penetrating wound being recognized, what was there to be done?
Exactly the same thing as for fractures complicated with a small
wound: close the wound, bringing the edges together as well as pos-
sible. You remember that I made this occlusion by means of strips
of muslin soaked in collodion and overlapping one another, and I
completed the dressing with a thick layer of cotton and a roller
bandage drawn tightly over it, extending from the lower third of the
leg to the upper third of the thigh. Then the limb was placed in a
wire splint.

You have doubtless not forgotten what I then said of the fears
which I had for this patient, and of the object proposed in treating
him in this way.

I feared articular suppuration, and I sought to avoid it. 1st. Why
did I have this fear? Because experience has taught me, as it has
taught all other surgeons, that suppuration comes in such a case after
a very feverish, acute, or hyper-acute arthritis which greatly affects
the health, and when once established it may be complicated by a
purulent infection which may carry oft* the patient, or by a hecticity
which may lead to amputation. It has taught me, on the other hand,

TRAUMATIC ARTHRITIS OF THE KNBE.

Et, when Buppuration does uot take place, the consecutive arthritie^
laiiia subacute, is accompanied by a moderate fover, or may evett.^
remain without faver, does not expose the patient to any fatal j
dent, and only threatens him with a more or lesa complete anchylosi*

2d. How did I seek lo avoid this acute suppuration which isi
almost as much to be feared as that of the large, long bones? By '
the same means and with the same intentions as in compound frac-
tures (see page 105) I wished, by keeping the edges of the wounds
together, to favour their immediate reunion or organization, and to
proiect them from suppurative inflammation which would be ver^ 1
likely to extend to the synovial membrane. I wiaheil also to avoi^l
the entrance of air into the articulation, for this air might have-^
favoured, during tlie first few days, primitive septicaemia or traumatic
fever, by the decompoaition of the effused blood and synovia, and a
formation by them of septic materials; and it might afterwards have
favoured the decomposition of the pus itself, decomposition rendered
• easy by its retention in a large anfractuous cavity with rigid walla,
which cannot expel the contents by retraction,

You remember what took place. Our patient suffered very little. J
His pulse did not rise above 90, nor the temperature above 10(iJ°,|
The very moderate fever which he hail may be considered as a slighsl
traumatic fever by reaction, while, if the arthritis had suppurated,*
the traumatic fever would have been intense, and probably septicEBmia*
Twelve days aiterwarda, I unrolled the band and removed the wad^
ding as well as the strips soaked in collodion. The wound was^l
entirely cicatrized. The articulation was but slightly swollen, an<3,|
showed neither heat nor fluctuation. Nevertheless, I reapplid
roller bandage.

To-day we have reached the sixteenth day. The general healtkB
continues good. The local condition improves. The patient will
begin to make voluntary movements while remaining in bed;
shall also communicate some to him every morning and evening, audi
if he can support this little exercise without a return of acute inflam-M
mation, he will get well, and will preserve neither rigidity nor pro-«
longed pains. His age, as I have often told you, singularly aids thid
fiivourable termination.

Observe, gentlemen, that if this young man has not had articularJ
suppuration, he has, nevertheless, had an arthritis, and, as this hasll
occurred after a penetrating wound, I am justified in adding ttiat hoj
has had a traumatic arthritis. I shall presently show you other ex-fl
amples of arthritis which deserve this name, but beforehand, I wislid
to put you on your guard against the signification of this wordj
which, in the language of some authors, has become the synonym oP
suppurating arthritis. You have here seen that the arthritis has
been neither acute nor suppurating, and yet it is impossible not to
recognize that its origin was exclusively traumatic. That simply

means that traumatic arthritis may be either suppurating or non-

Wppurating. Now, as articular inflammations, after the ocourrenoa ,
r external violence, are much ofteoer suppurating than non-suppu-
pAiug ; this is a reason for not contiouiug to give the word trttuuitttio^

swiU I
ve to I

286 DISEASES OF THE iKTICULATIONa,

arthritis this eignifiration of synovitis abtjiit to suppurate. We
distinguish two varieties of traumatic arthritis: one conaeoutiv
penetrating wounds, and for which suppuration is to be feared and
to be avoided ; the other consecutive to lesions without solution oE
continuity, and for which suppuration is entirely exceptional.

II, Contusion and sprain of the knee; Consecutive Iraumalic arthniis. —
Consider, for example, that which is going on in the two men, Nos.
24 and 46 of Ward Sainte Vierge. The first ia a mason, 30 years old,
who fell upon his left knee while walking fast. He thinks he did not
twist the articulation violently, and we are not justified in believing
that there has been the exaggerated tension of the fibrous tissues,
which ia the initial lesion of a sprain. He has probably had only
an exaggerated pressure, that is to say, a contusion which has torn,
if not the synovia] membrane itself, at least some one of its blood-
vessels. The patient has been here for three weeks; you know there
have been no general symptoms, and that, as local symptoms, we
found at the beginning: All movements impossible, a sharp pain'
when the patient tried to make or I sought to communicate any, a
little heat felt by the hand on comparing the two knees, and finally
a slight swelling and a fluctuation perceived by the manceuvre which
I have often had occasion to show you (see page 157). By these
symptoms I recognized the existence of a subacute arthritis which I
did not hesitate to call traumatic, and for which I told you that I did
not fear suppuration, because contusions of the knee are very frequent
in the hospital, and because we never see the consecutive arthritis
terminate in suppuration.

The second. No, 46, is a teamster, 42 years old, who, jumping
down from the back of his horse, fell upon his knee and twisled hia
leg, as he himself says. He felt quite a loud crack, and was not able
to get up. He'was brought to the hospital a fortnight ago. We
found in him the same apyrexia as in the preceding case, and the
same functional and physical symptoms. Furthermore, making an
assistant hold the lower part of the thigh firmly with both bauds,
and taking hold myself with one hand of the lower end of the leg,
and moving it alternately to the right and left, I found that lateral
movements took place in the articulation. Then, placing one hand
above ihe knee to fix the femur, and the other just below, I pressed
with the latter the head of the tibia alternately outwards and inwards,
and felt the bone move a little in each direction. No doubt, then,
there was abnormal lateral mobility. It was one of those cases of
aprain in which the distension of the ligameuta, instead of causing an
occult or hidden lesion, aa so often happens in the foot, had been
followed by rapture of the lateral or of the crucial ligaments. In a
word, it was a sprain with rupture of the ligaments.

I told yon at the beginning that the patient would have a non-
suppurating traumatic arthritis, and that in his case we bad to occupy
ourselves with three principal consequences of the injury : the effusion,
the consecutive stift'ness, and the lateral mobility. I shall return to
these points in a moment, but now I wish to fix your attention upon
this, that there was, as in the preceding case, a (^uite severe artbrili%

TBADMATIC ABTHBITI3 OF THE KNEE. 28T '

that thia arthritis !iad no tendency to suppurate, and that, nevertheh
on account ofitsorigiD, and to distinguish it from rheumatismal, gouty,
and scrofulous arthritis, we are obliged to name it traumatic arthritisi

Recall the arthritis of the knee, which you have known to folloi
fractures of the patella and femur (see pages 142 and 157); they all
were Iraamatic arthritis, sometimes subacute, and sometimes chronio,;
but having no tendency to suppuration.

I should like to complete this account of the symptoms by thai
the lesions which correspond to them ; but on this point I am not
well informed as I should like to be, because we do not often have
occasion to make an autopsical examination of articulations aftected
in thia way. However, by making use of the notions furnished by
experiments upon animals, and those which we have been able to
obtain from time to time from our patients, I feel authorized to tell
you this.

In arthritis of all kinds there exists a primitive lesion of the syno-
via! membrane — injection of the vessels, which we may also call
hyperemia or congestion. This was well seen and described by Prof.
Eichet,' by Bonnet (de Lyon),' Panus,' and Oilier.* Then follows a

t second lesion, closely associated with the Srst, thickening of the
!»ynovial membrane by the exudation of plastic matter into the con-
■jiective tissue which supports its epithelium, and by the deposit of
'fiilse membranes on its inner surface. I shall not speak now of the
(tjther lesions of arthritis, because they occur rarely in cases of this
^nd.
In traumatic arthritis especially, I am authorized to believe that the
dominant lesion is hyperteinia, that which made Bonnet describe the
congestive form of arthritis, and that when plastic and neomembranous
thickening occurs it is but slight. This belief is justified by what
clinical history teaches us as to the most common mode of termination,
and by comparison with what occurs in a certain number of spon-
taneous, acute, and subacute arthrites. Thia termination is complete
resolution after a shorter or longer time, especially when the patients
are still young. Now, I readily understand this perfect resolution
and restoration of movement when there has been only hyperemia,
or when the plastic deposits are not very abundant. Moreover, you
will see that this an atom o- pathological problem and the relation of
'the lesions to the course of the arthrites is the principal difficulty in
the clinical study of these di-iieases.

I wish now to examine before you the question, What will be the
duration and the termination of the subacute traumatic arthritis of
our three patients? Relying upon what I have just said, and the
analogy with the facts of the same kind which I have seen in the

Richei, Memoirs fur ten Tninvnrs Blanabes (M^inolreB de I'Acad^mle de MMeoine,
Is, 1853, tome Jtvii. p. 37).

Bonnet, Traits ds« Maladlen dus Artlcnlationa, Lyon, 1B4G ; Th^rapeatiqas dea
MftladJHB Articnisirea, Paris, 18&3.

' P&nas, ftrtiole ArtlrnUtiona dti DictiotiDaire de Mideeine et de Chirargle Pra-
tlqnea, Paris, 16aS, tome ili. p. 2liS.

* Oilier, artlclo Artiunlalious da DlolJoanaire Euc^olopf^dlqus des Svieooea MMU
DftleB, PnriB, 1867.

■■M

28a PISEASKS OP THE ABTJCULATIONS.

hospitals, I can only say that tliey will last at least five or six weeks,
perhaps much longer, in consequence of the passage of the disease la
the condition of chronic arthritis.

As to the mode of termination, it may take place in one of the three
following ways : —

1st. In resolution and complete restoration of movements;

2d. By passage to the chronic condition, with possible termiaatioo
ultimately either in resolution or in anchylosis;

8d. By transformation into that variety of incarable arthritis which
we call dry arthritis.

I hope for the first of these terminations, that ia to say, cure with
restoration of functions, in the first of our patients, in him who had
the penetrating wound; for he is youn^, and from the moment that
he escaped suppuration hia condition ia the moat favourable for the
complete disappearance of the alight congestion and thickening which
undoubtedly have been the principal lesions of his traumatic arthritis,

I may also hope for this termination in our second patient, who baa
'a contusion without sprain. Still, nothing assures me that there will
not here be a tendency to pass to that va;riety of chronic arthritis of
which 1 have often spoken to you in connection with fractures, which
leaves for a long time a little swelling, more or less hydrarthrosis
pains while walking, and returns from time to tiine to the subacute
condition, to end finally, after lasting for several months, either in
cure, or in a complete or incomplete anchylosis. If he is willing to
take care of himself for the necessary length of time, it is probable,
since he is not very old and is not rheumatic, that he will escape termi-
nation in an infirmity ; for I presume that the principal lesion is stilt
congestion, and that the interstitial and neomembranous exudations
are not so abundant and have not the same tendency to a definitive
organization as in many spontaneous arthritea, and that, therefore,
they have a greater tendency to be reabsorbed.

Aa to the third there is no certainty, for clinical history affords me
no means of foretelling the termination of subacute arthritea. Bat
there are tnore reaaona to fear in hia caae passage to dry arthritis,
without anchylosis, which would still be an infirmity. These reasons
are, the age of the patient^ the rheumatisms which he tells me he has
aJready had several times in the different articulations, the deterlo
lion of his health by the use of alcohol, and the existence of a let'
(rupture of the ligaments) which ia sometimes incurable, or whiul
be cured, needs prolonged rest, rarely accepted by patients.

You see then, gentlemen, for these patients there is one thir^
is certain, that no one of the three will have that which is tSe t
to be dreaded in arthritis, acute or chronic suppuration of the ji
there is another thing which is probable, cure after a longer or shoi^
time, with restoration of the shape and functions, and behind 1"
probability a little uncertainly as to the possibility of an incompj
anchylosis or a consecutive dry arthritis.

It is now the moment to tell you that suppuration of the 1
articulations ordinarily takes place under three circumstances:
After a penetrating wound, when suppuration of the external, VI

TRAUMATIC ARTHRITIS OF THE KNKK.

has not been prevented, or when there is a concomitant fracture, i
in gunshot wounds; iid. When tlie paiient is scrofulous; Kd. Aftea
those dangerous fevers which seem due to an infection, and have morfl
or less nnalogy with pyaeraia, such aa puerperal and urinary fevers
sometimea. and such as we see in the oourae of severe erysipelas aniffl
purulent infection, properly so called ; and it is because our thref
patients are in mine of these conditions that I am sure ttiey w'"
have purulent arthritis.

TherapeiUieal indicalions. — T have already mentioned these for th(4

rst patient, the one with traumatic arthritis due to a penetratinj_^
wound. The chief iudieatiou was to prevent suppuration. I hav((J
itold you how it was met.

There remains for him an indication which is the same for the tw<3
others — to prevent passage to a ehronic state, and termination \^
infirmity. For that we recommend, above everything, rest in bedS
then compression with the cotton dressing, to be renewed every f
or six dttys. To that we shall add occasional purging. Thus far f
see no indication in the sanguinolent or serosanguinolent effusion.
Twice during this year (1872) you have seen me make a puncture
and aspiration upon patients, who, after a contusion of the knee, had
a considerable effusion of blood. I then gave you my reasons for so
doing. I feared that the effusion, on account of its volume, might
not L>e reabsorbed, and that, acting aa a foreign body, it might cause
permanent irritation and passage to the simple chronic state, or to
the form of dry arthritis. I thought that by at once evacuating the
liquid, I should remove this cause of prolonged irritation, and put
the patients into conditions favouring termination by resolution, rest .
and compression being also used, as is necessary in all oases o'
kind.

In the two patients now before us the effusion is small; it wad]
formed so slowly that I may believe it was composed of as much, andj
even more, synovia than blood. I count upon the absorption, which.l
is the rule in such cases, and I shall puncture only if, three weekaj
hence, I find the absorption going on too slowly.

The rupture of the ligaments and the resultant lateral mobility'
furnish us, in the third patient, the indication to immobilize for ivj
much longer time than in the other two. About two months will bej
necessary for the consolidation of the ligaments. In order not tdjl
condemn the patient to so prolonged a rest in bed, I shall put a dex-J
trine bandage over the cotton dressing at the end of the third week,™
and leave this immovable apparatus in place for four or five weeks.
If, at the end of this time, I still find lateral mobility, I shall renew
the apparatus and leave it in place for another month. I do not dis-
guise the fact that this prolonged immobility will favour anchylosis;
but that result is far from certain, for anchylosis results from two
things: special lesions, which I shall hereafter describe, and immo-
bility. The latter, by itself, would never cause anchylosis. It only
favours it by preventing us from employing at a certain moment the
movements necessary to prevent its establishment. But, on the one I
baud, if the lesions which produce the anchylosis are uot too markedjj

290 DISEASES OP THE ARTICULATION'S.

we shall still be able, at the end of three months, to use successfully
the movements of which I spoke; and, on the other hand, if perma-
nent anchylosis should occur, such a result would be less unfortunate
for the patient than persistency of lateral mobility. For the latter
exposes the knee, at every moment, to new sprains and, consequently,
to renewed arthrites, which are more troublesome than complete
anchylosis.

There will probably be, in all three patients, a final indication,
that of favouring the restoration of movements and diminishing pro-
longed rigidity. But as the means appropriate to that are the same
as in cases of spontaneous arthritis, I will speak of them when treat-
ing of the latter.

LECTURE XXXV.

ACUTE AND SUBACUTE SPONTANEOUS ARTHRITIS OF THE KNEE.

I. First patient aflFected with acute arthritis of the right kuee, gODorrhoeal, with con-
tracture of the flexors— Straighteni rg of the limb under ether — Afterwards,
discovery of lateral mobility and crepitation — Explanation of these two symp-
toms. II. Second patient aflFected with single acute arthritis, probably rheu-
matic, of the right knee. III. Formation of a complete anchylosis in both cases,
notwithstanding the eflforts made to prevent it — Study of the lesions — Congestion
— Plastic deposits, whence the name plastic or auchylosing arthritis — Explanation
of the anchylosis by the establishment of adherences after a struggle between
the tendency towards resolution and the adhesive tendency. IV. Therapeutical
indications based upon these ideas.

Gentlemen: You have seen for more than six months in ward
Ste-Catherine two women who have often given me occasion to speak
to you of the acute and subacute forms of spontaneous arthritis of
the knee. Both are now getting well with anchylosis. As cases of
this kind are not rare, and raise thorny questions of science and prac-
tice, I propose to-day to recall the principal details of these two obser-
vations and the reflections which they have suggested.

I. Acute arthritis of the right knee, gonorrhoeal, with contracture of
the flexors. — One of them, 25 years old, occuj)ying bed No. 24, ward
Sainte-Catherine, was admitted the 29th of December, 1S71, into the
medical service of my colleague M. Pidoux. She had been taken a
few days before with sharp pains in the right knee, accompanied by
slight fever and loss of appetite. When she was brought to the hos-
pital, the pains were still very severe ; not only was she unable to
make any movement, but the knee was flexed to a right angle with the
thigh, and she was unable to straighten it, the slightest attempt to do
so increasing her pain. At the same time the skin was Lot, the pulse
at 90, and there was sleeplessness, and very little appetite. In a word,

8PO^TANEOCS ARTHRITIS OF THE KNGB.

rtlie intensUy of the local inflammatory symptoms and the peraiatenoy
of this slight febrile condition indicated that the arthritis belonged to
the acute form. Furthertnore, M. Pidoiix hsid discovered that this
arthritis was single, and that the patient hail a purulent urethritis
and vaginitis which authorizetl him to consider the disease as of gon-
orrhceal origin.' The 17th of February, that is, more than six weeks
afterwards, the general condition had improved, but the local symp-
toms remained about the same, and M. Pidoux asked me to take the
patient into my service, I then found that the knee was flexed at a
right angle, in consequence of which the patient was forced to lie up-
on the corresponding side, that it was swollen and felt very hot lo the
hand, and that the least pressure, and of course the slightest attempt
to move it, caused very severe pains. When T asked the patient to
point out the chief seat of these pains, she always indicated ihe inner
side of the knee, the part which corresponds to the passajje of the
interna! saphenous nerve and to the insertions of the internal lateral
ligament. On account of the flexed position of the limb, I was not
able at first to determine whether there was any effusion of liquid;
however, if there was, it was not very abundant, for I did not find any
fluctuation.

I further recognized that for the moment tLe patient had no other
joint affected, and that she was without fever. It was then a single
arthritis which had at first been acute, and which, in consideration of
the disappearance of the febrile phenomena, might he considered as
having passed to the subacute state. Was this arthritis to be called
rheumatic? Strictly speaking, yes; for by this rather vague word
rheumatism we wish to designate a general cause, the essence of which
is unknown, which affects the synovial, fibrous, and muscular tissues.
Furthermore, gonorrhcea also was present, and whatever may he the
,way in which the production of gtinorrhoeal arthritis is explained, it
is certain that, in its symptoms and consequences, it resembles certain
forms of rheumatic arthritis, especially that in which the disease is
single, or very marked and prolonged in one articulation, whilst ihe
Others are but slightly affected, and in a very temporary manner.
Moreover, if any douhtamight have existed as to tlie rheumatic nature
of the affection, they would have been destroyed when, a few months
later, in June, we saw this patient affected with pains in several other
joints, especially those of the shoulders and left elbow. As lo the right
elbow, it had lung been completely anchylosed by fusion in conse-
quence of a traumatic lesion during childhood.

On mating my etiological examination I noticed upon the neck
the acara of two ganglionary abscesaea, and upon the borders of the
'eyelids a little alopecia and redness coinciding with alight specks left
iby keratitis during childhood. The patient, although apparently of
a good constitution now, hud then the scrofulous temperament. The

' I ngrne with those wba think tUnt gnnorrlifral arthritis is rlienmBtio. But a\\\\U
calif It de^rvea mHution and s special daaoHption for the Tnllowine rvason, wliicli is
Sbsolntely iu<>s[ilioal)l» : it ix Inimlliad mauli moro freqnnully than oriliuarj aouls
tbeuiuatiein In a aiiigle artlcnlatiim, and tbera gnea bey mid the cmigesCive form uud
tokaa on tbe plaatiu and ancb^'lusing [onO) of wblub. 1 eball sf eal^ iu tbi$ ]^9i;tui:«t ^ •

!S^H

. 2t*2 DISEASES OF THE ARTICULATIONS.

I local symptoms do not in any manner authorize me to admit a Bcro-
a arthritin, but these antecedenta might make me fear, in case thia

I acute arthritis should become a chronic one, that it might pass to the
fungoid form or white swelling.

However that may be, there was when I first examined this woman
one main indication to meet: that of straightening the knee, thus
applying the excellent precejjtB given by Bonnet' for the aubstitution
of H good for a bad posture in diseases oFthe articulations. The patient
was then anaesthetized by means of ether, and I straightened the limb
very easily by my hands alone, placed it in a wire frame and kept it
in place by means of a cushion, an anterior splint, and five straps.
Since then the pains have not been so violent. They reappeared
however from time to time, especially when the patient moved a little
too much, and after we ourselves bad made an examination or sought
to give motion to the articulation, whiyh we knew to be threatened
with anchylosis. At a certain moment during these explorations we
discovered lateral mobility, as in the man suffering from a sprain of
■whom I have previously spoken, and at the same time a loud crepita-
tion which appeared to me to be caused by the friction of the bony
Burfiices, In a word, after about two months of treatment, the arthri-
tis had passed to the chronic slate with the two chief symptoms which
I have just mentioned.

To what were these two symptoms due? I again repeat that we
do not well understand all the lesions of the beginning of acute and
subacute arthritis, because we have not had occasion to study them
on the cadaver, and because the only information we possess has been
furnished by experiments on animals, and especially by those which
Prof. Richet has described in his works on white swelling. Now
these experiments probably do not reproduce all the lesions which
occur in the living man, and especially those which would explain
the symptoms in question, I shall then give you only very probable
opinions, warning you that I cannot verify them by direct observa-
tion.

As for the abnormal lateral mobility I am disposed to attribute it,
like that which I observe after violent sprains, or in patients with white
swelling, to a lack of resistance in the lateral ligaments. But I do not
disguise from myself that in an articulation where the synovial mem-
brane is thickening and advances, as I shall soon tell you, toward
fibrous transformation, it would seem as if the ligaments ought to
ollow a similar course, and increase their resistance by a thickening
and condensation of their tistsue. We should then have to admit that
here the ligaments have a tendency, in consequence of the arthritis,
to lose in part their fibrous character, while the synovial membrane
tends to assume this character. It would be strange ; but after all it
ia not impossible.

And it is because it seems to me strange that I offer you another
explanation ; perhaps the lateral mobility is caused by the semilunar

19 lies Articulation? ; Lyou, lS4li, T]]£rnpeiitlgna ^^H

SPONTASKODS ARTHRITIS OF THB KMBK.

299<

rfibro-cartilages being softened, thioned, mid abtmt to disappenr. Foi
I can under'^taTid that if these intermedinte bodies were lacking, tb^j
two bones would approach one another, the ligaments would slaekei
and iose the tension which, during extension of the limb, was the prin
cipa! obstacle to lateral mobility. What authorizes me to offer joi
this supposition is the fact, that, in all articular diseases which have been'
a little prolonged, the trouble in nutrition whieh follows causes, by a
mechanism which we do not understand, the destruction of the diar-
th rod ial cartilages. Nowas the fibro-cartilages have a similar structure,
I presume that, as moreover we see it in white swelling, their cells
open, are destroyed, and disappear, and that as the cartilaginous por-
tion is disassociated and absorbed, the fibrous portion either disappears
itself by absorption, or is no longer thick and firm enough to fill the
apace between the two principal bones of the articulation.

I have now to explain the second symptom, the crepitation. I cai
attribute it to nothing else than to that destruction of thediarthrodiaj
cartilages of which I have just spoken, a partial destruction undoubt-
edly, but nevertheless occupying the whole thickness in certain points,
and thus permitting during lateral motion the rubbing of the bones
which we felt. I repeat that this singular destruction of the diar*
tbrodiai cartilages, first noticed in white swelling, then in dry, deforms
ing arthritis, seems to occur in almost all arthritea when they have
certain intensity or last for a long time.

I omit, for the moment, the later phenomena which we observed!
and the present condition of the patient, for, in these respeclw, she re*'
sembles another woman. No. 3, whose antecedents I will now recall-,

I and will then complete the account of the two observations.
II. This second patient. No. 3, is 2'd years old, and, like the precei
■ing one, has had no children; she knows no cause to which to attri
bute the very painful affection of the knee from which she was suffei
'ing when admitted to the hospital the 3d of April, 1872, The d-
then had lasted a week, and was accompanied by a slight febrile t
ment. The local symptoms were a notable swelling, a small effuaii
within the joint, considerable heat felt by the hand, very sharp
pain on the slightest movement, and much spontaneous pain during
the day and especially during the night. In a word, the general and
local symptoms were those of moderate acute arthritis. In her case

» there was neither the permanent flexion nor the lateral motion which
we found in the other. We have treated this woman by immobility
in a wire splint, several applications of wet cups, several blisters,
purges,opiates, and sometimes, when thepaina were very severe, by the
aubcutaneous injections of the hydrochlorate of morphine. You have
noticed frequent renewals of pain and even of fever, which made me
fear suppuration; but this has not occurred, and after several weeks
all these symptoms were bo much better that I have no longer ha<L
this fear, and have considered the disease as having passed to th«
chronic state. '

III. Since about the 15th of June the two cases have been so similnr
that I can complete their history at the same time. Finding myself
in presence of a disease which had kept ilie articulation imniovuble

DISEASES OF THE ARTICULATIONS.

■^

and threatened to end bj aneliylosis, I tried to prevent this result and
obtain a cure with preservation of the functions. With this object I
communicated a few movemenia to the limb every morning, and ad-
vised the patients to do the same. The nianceuvre was repeated in the
evening by the interne of the service. But see what happened : not-
withstanding all their efforts, the patients were not able to bend the
knee; their muscles Hid not contrRct, and the only movements which
took place wer-e in the hip and thigh. As for those whii;h we com-
municated during about a minute each time, they were very limited
and caused pain which lasted for quite a long time thereafter. At the
end of a week these pains increased, so that it became necessary to
stop all motion and return to poultiues, A few days later we recom-
menced, with the same result. I therefore had to give up my attempts
ind let the articulations rest.

To-day, the end of July, in both patients the patella is united to
the femur; the 6rst (No. 24) has lost all movement of the tibia upon
the femur; the second (No. 3) has atill a few movements, but they are
very limited, and I expect to see them disappear entirely. In both of
them we shall have subacute arthritis terminating, after passage to
the chronic condition, in complete anchylosis. I have shown you, in
, addition, that since the beginning of the disease the femur has seemed
to be lurneBed to a great distance above the articulation. To-day,
when I compare it with that of the opposite side, I And a swelling
similar to thsit which we have often seen after simple and eompounil
fractures, and after epiphysary osteitis, a swelling which we call hy-
perostosis.

Let us now see, gentlemen, 1st, what have been the anatomical
lesions in these two women ; 2d, why, in spite of all our efforts, the
cure did not tiike place with preservation of shape and functions.

1st. Aa for the. lesions, it is certain that in the synovial membrane
they consisted of a hyperamia and inflammatory exudations, some of
them deposited in the membrane itself and making it rigid, others on
its inner surface in the form of fibrinous and neo-membranous flakes,
which became vascular and were transformed into a fibro-cellular or
fibrous tissue. It is for the sake of better characterizing this capital
lesion and to distinguish it from those of fungoid and dry arthrites
that you have often heard me era|iloy the expression plaslk arthritis.

While these lesions are being produced in the synovial membrane,
what is taking place in the other constituent parts of the articulation ?
\ That is what autopsies have not yet well cleared up. I presume, aa
I have already said, that the diarthrodial and inter- articular cartilages
are disorganized and thinned, and perhaps have disappeared. It ia
mora than a presumption in the case of the first patient; for we have
not been able to otherwise explain the crepitation which we found in
her at a certain time. But is this lesion entirely similar to that which
we find in white swelling and dry arthritis, or ia it different? Do
Brodie's ulcerations and Redfern's velvety change occur here?

Or is it by the histological lesions, the knowledge of which we owe
to M. Ranvier, especially by the proliferation of the superficial cells,
the segmentation of the fundamental substance, and the opening of the

SP0NTANE0D8 ARTHRITia OF TBH KNKB. 29o

capsules into the articular cavity, that ihe supposed destructions com-
menced? I cannot answer tbese questions, because the authors I
mention have not made a sufEident number of autopsies to be able
to say whether the lesions which ihey describe in dry arthritis are also
found in ancbylosing plastic arthritis, or at what period of the disease
they appear.

yo also for the ligaments ; are they softened and destroyed, as we
might have supposed, in the first patient who has had lateral mobility
from the beginning? Are they not, on the contrary, thickened and
rigid, in consequence of tlieir participation in the plastic phlegmasia ?
On this point also I am in doubt.

And the bones 1 I have noticed nothing in the patella or the tibia,
but I told yoii that the femur seemed notably hyperostosed in both
patients. Is it the periosteam alone which has been invaded by pro-
pinquity, and which has furnished new layers of bone by a periostitis,
likewise plastic ? Or has the entire thickness of the bone been aft'ected,
passing to the condition of plastic or condensing osteitis? I do not
know. But on this subject I ofter you a final reflection which haa
already been mentioned Apropos of osteitis. I have often seen hyper-
ostosis follow triiumatic and spontaneous arthritea when they had not
talien on the fungoid character and the tendency to chronic suppu-
ration, or, which amounts to the same thing, when the patients were
not scrofulous. I therefore believe that in cases where we have
doubts as to the nature and the tendencies of an arthritis, the certain
appearance of hypertrophying osteitis is an argument in favour of the
opinion that this arthritis is plastic rather than fungoid and suppu-
rating.

2d. How and why was this complete anchylosis established 7 Two
chief incontestable reasons explain this termination : First, the false
membranes formed adhesions Hlte tho.se we find on serous membranes
after inflammation; these adhesions, becoming more and more firm
and rigid, have diminished little by little the synovial cavity and op-
posed chan>;e in the position of the articular surfaces. Secondly, pro-
longed immobility has favoured tbese adhesions. This immobility it-
self was due both to the pain w'hich permitted neither voluntary nor
communicated movements, and to the muscular insufficiency which
was itself the consequence of these pains. For there are produced
during the course of painful arthrites remarkable physiological and
anatomical modifications of the muscles. They cease to contract vol-
untarily, and assume a prolonged eontrticture which completes the im-
mobility in the position either of flex ion or of extension. You remem-
ber that in one of our patients we had to straighten the knee after hav-
ing overcome the resistance of the contractured 6exors by aniesthesia.
When the first efteut, contracture, has lasted a certain length of time
the perl-articular muscles atrophy, then pass to the fibrous and fatty
condition which characterizes retraction. The longer these lesions
of the muscles last, the more do they favour the establishment of the
anchylosis by allowing the formation and organization of the adher-
ences of which I have just spokeu.

It is now the momeut, gentlemenj to define our opinions upon the

296 DISEASES OF THE ABTICU LATI OSS,

iiifluenee oF immobility in the pro'luolifin oT ancliyl"si3. It does not
by itself produce it, only when combiited witli a plastic arthritis. But
it may happen that this Intter ia ciiused by the immobility itself,
KecnII in this connection the distinction which I have often made be-
tween large and small articulations, at least so far as traumatic artica-
Inr diseases are concerned. Immobility alone rarely causes plastic
arthritis in the large juinta, and if the latter occurs it is due to exter-
tisl violence. The contrary is the case in the small articulations. Im-
mobility alone may there cause plastic arthritis and consecutive anchy-
losis.

These resulta do not seem to me to agree with M. Charcot's. In
his recent works this author has described an arthritis of the large ar-
tictilalinns in paralytics; but the immobility does not seem to me, in
such cases, to be the sole cause of the articular phlegmasia. The
troubles of the nervous ayaiem undoubtedly contribute to a certain
extent, and the conditions arc not the same as those of immobility
after great traumatisms.

But let us return to the mode of production of the anchylosis of the
knee in our patients. Is there no reason to lay it to the charge of
(itherciiuaes than those of which I have just spoken ? I think there is,
but [ am not suf^ciently acquainted with al] the alterations that have
oecurreil, to affirm it. It may be, for example, that the diarthrodial
and semilunar cartilages having been completely absorbed, the surfaces
of bone thus laid bare and attacked by plastic osteitis have united by
a mechanism analogous to that of the formation of a callus. There
would then be established an anchylosis by fusion of the bones. It
may also be that the cartilages not having been absorbed, fusion has
taken place between them, and that thus the anchylosis may be by
cartilaginous fusion, a form which is much rarer, but which has been
observed, and of which I have seen an example. Or it may be that
thecartilageshuvingbeen preserved, false membranes have formed upon
the opposing aurfacos, and that solid adhesions have taken place be-
tween them. The anchylosis would then be calletl fibrouH.

"We are unable to recognize clinically in the living patient with
which of these forms indicated by pathological anatomy we have to
deal. This would be a source of regret if therapeutics could do any-
thing for complete anchylosis, that in which all movement has disap-
peared. But I am of those who believe that in auch cases nothing
should be done. The indication, either to oppose anchylosis itself, or
to substitute a good for a bad posture, exists only in those cases in
which some movemenla recnain and the anchylosis is incomplete.
Now, anchylosis may be incomplete in two ways : first, by tHe thicken-
ing and lack of extensibility of the synovial membrane, consecutive
to the eel lulo- fibrous, and even fibrous transformation of the phistic
materials depositeii in it, it is then incomplete anchylosis by rigidity;
second, by the establishment of adhesions which are atill extensible
and susceptible of resolution between the opposite points of the syno-
vial membrane, in which case the anchylosis is called cellular or ad-
hesive. You understand, finally, that the incomplete anchylosis may
be at the same time adhesive and by rigidity.

SPONTANEOUS ARTHRITI3 OF THE KNSK.

T now reach the second question, ii very interesting one clinicall:
tliat of knowinEC why compltite anchyloaea are produced. It is fi
because the artbritia has passed beyond the limits of that which is
ply congestive, aa happens quite often in the traumatic variety
fiillowing contusions and sprains, and because by passing these limits
it becomes pjaatic ami adhesive. But ali plastic arthritea dn not end
in complete anehyloaia: a p;oodly number end in the rigidity :
■ cellular adhesJDns of which I have just spoken, and which we fin;
overcome. What takes place in such eases? The congestion dii
pears, the inflammatory products infiltrated in the thickness of
synovial membrane, and which have given it its rigidity daring a <
tain time, do not go very far in their fibrous trausfurmatiori, and ii
be reabsorbed; the false membranes, if there have been any, are i
reab:iorbed ; the synovial membrane again becomes supple, and tl
articulation returns to its norma! condition.

In our two patients the plastic products, instead of being reabaorbei
have advanceil further and further in their organization, have m:
the synovial membrane fibi-ous, and have formed adhesions, while
the same time, in all probability, the cartilages and the ligaments hai
undergone the alterations we have mentioned. The capital different
then is this: the plastic arthritis instead of terminating by resolution;
haa terminated by adhesion, and consequently, by a profound tian
formation of the normal anatomical conditions.

Bat in making this explanation I only move the difficulty bad
Why, in fiict, this unfavourable termination rather than the firsl
Hare I can no longer answer with pathological anatomy, we must tui
to pathogeny, that is, to that which is the most obscure and the mi
difficult, and yet the most real in our science, These women
,got their infirmity because they have had a very intense inflammatii
of a peculiar kind. Tlie intensity has caused the primitive congesti
and the consecutive exudations to be more marked than they are
other cases; the nature or the special mode of inflammation lias be
auch that the tendency has been towards organization raflier than a
sorption of the plastic products. Has there been a special cause?
is probable; but we do not know what it is. We say, since we ui
do no better, that this cause has been rheumatic; we say, for one
the patients at least, that the rheumatism haa been gonorrhceal. Bi
since rheumutiam produces also arth rites which are simply cougestiv
t>T plastic non-anuliyloaing arthrites, or still others, it remains to kno
why it has taken the form which v/e have observed upon our tw
patients. Probably we must here accuse, as we are so often forced '
do, a peculiar aptitude, an idiosyncrasy behind which lies — we should
not hide it — our inability to explain the relation between the etiolo^jj
the intensity of the lesions, and the tendency of these lesions to a '
Tiinoe in one direction rather than in another.

Let us confine ourselves to the (ieductions which are applicable
■the clinic. These deductions are the foli<jwing: when you have n
rnized that an arthritis, whether traumatic or spontaneous, is neit
ippurating, nor fungoid, nor dropsical, nor dry, do not forget the
plastic, and that conaeLiueutly it has a certain tendency towards

29H

298 DISEASES OF THE ARTICULATIONS.

chylosis, a tendency which you must combat by exciting or favouring
resolution, and preventing adhesion.

IV. Tha-apeiUical indications, — They result from what precedes, and
belong to three periods of the disease. In the first, that of the beginning,
the intensity of the phlegmasia must be opposed by rest in a good
position, antiphlogistics (leeches, cupping) derivatives upon the in-
testinal canal, narcotics to quiet pain.

In the second, you must try to provoke and aid the absorption of
the plastic products. It is still rest and immobility which meet
this indication; revulsives upon the skin, blisters, punctate cauteriza-
tion may also aid it.

In the third, you must try to make the adhesions, which are still
thought to be soft, and the rigidity, which is not yet invincible, yield.
It is then that it is proper to try massage and communicated move-
ments. But here we find ourselves between two dangers : that of pro-
voking, by these movements, a return of the phlegmasia, and that,
by not employing them, of allowing the anchylosis to form.
We are obliged to feel our way. If the manoeuvres cause only
temporary pain it is proper to persevere; if, on the contrary, they
provoke continuous pain, with return of the swelling, of the articular
eff^usion, and of heat to the touch, they must be stopped. Perhaps a
little later they may be borne; if they are not it is best to abstain en-
tirely and to abandon the arthritis to the chances of anchylosis, as we
have had to do for our two patients. At this same period if the artic-
ulation has become indolent enough to allow the patient to leave his
bed and walk on crutches, baths and douches of sulphurous or thermal
waters, such as those of Neris, Bourbonne, and Plombi^res, would also
be very useful.

LECTURE XXXVI.

CHRONIC ARTHRITES OF THE KNEE.— HYDRARTHROSIS.

Dropsical arthritis or hydrarthrosis — Lesions supposed to exist, but inappreciable
bj physical signs — Probable congestive form — Enlargement of the patella, ex-
plained by a hypertrophy ing osteitis — Prognosis — Long duration, possible relapse
— No tendency to suppuration and to anchylosis — Therapeutical indications : 1st
curative treatment : compression, blisters, puncture, actual cautery, injection of
iodine ; 2d prophylactic treatment.

Gentlemen : We have at this moment in the wards several patients
suffering from chronic affections of the knee. When passing their
beds every morning, I indicate by a word what there is that is charac-
teristic in each one of them, and I recall to you the questions which
should always preoccupy us when in presence of affections of this kind :
shall we have resolution, anchylosis, suppuration, or the infirmity of

IC ARTHRITIS OF THE KNEE.

29»1

! patients: I shall!
white swelling, auiiUl

dry arthritis? I cannot speak to _yoii of all theE
take only the three principal types : hydrartbroaia, \
dry arthritis. I begin with the hydrarlhroais.

Dropsical arthritis or kydrarlhTOsis. — The patient in No. 20 Is a mM
thirty yeara old, jeweller, of a medium constitution, but in whoa*
antecedents we find no indications of scrofula. He loM us that (
several occasions be had [iikins in the shuuMers, arm, and left knee,
which however have never been swollen. These paina, although ap-
parently rheumatic, had not been accompanied hy fever nor by such
an alteration of health that we could explain them by an acute artictt- J
lar rheumatism. ■

He entered our wards for the first time three years ago for a awell-B
ing in the right knee, the cause of which was unknown. lie remained ■
six weeks, and left ua almost cured, with a rubber knee-cap, which we
advised him to wear during the day and to remove at night. He was
able to resume work and continue it until a month ago. However,
he has always fell at times, especially when a little fatigued and v
the weather was damp, pains in this knee. Finally, a month and ft I
half ago, after a long walk, the pain became more intense, more pro- 1
longed, a new swelling appeared, and the patient was obliged to return f
to us.

He has been here four weeks. You noticed at first that the right I
knee wns awolien, that the depressions on each side of the patella were J
replaced by a tumefaction a^ppreciable by the eye, that the region waftfl
not hot to the hand, and that, by pressing with both hands upon the-*
Bides, while the index finger of the right hand pressed buck the patella, I
fluctuation was distinctly felt. There was further the sensation that J
the liquid was not separated from the skin by a thick layer, a
examining the prolongations of the synovial cavity, especially the J
upper one, we did not feel any thickening.

The diagnosis was not difficult; first, it was certainly an arthriti%l
since the swelling, the pain, the difficulty in movement, the heat fromj
time to time could be attributed neither to a simple neuralgia,' nor toM
a cancer, nor to any other disease. But we had next to make tha^
anatomical and the etiological diagnosis of this arthritis.

As to the first, the thing was evident; it was certainly a cbrc
arthritis, but with considerable effusion, so considerable that it was^
allowable to make use of it to characterize the disease as our authoi^
have done hy employing the word hylrarthroaia. Yon have ofte^l
heard me pronounce this word for the present patient, and for those^
who have been similarly affected. But I prefer generally the name
dropsical arthritis or arthritis loilh fffusion, because under this name of
hydrarthrosis are comprised two things: an essential effusion or one
without lesion, like that which is formed during anasarca, and an ,

I I Imve ofton spoken of patienta who, withonl any anlwrior disaaae, or sftai- a
niatii' or a Tiiotimalia Hrthrilis, lia<i a very aharp i!(iii tin anus puiti in tlie siHh o
knee, willi exaoBrbatioii during walhiuii or without known oiluse, ailii witlionl au;^J
oppf-oialilH swelling. Tha artiirilin had no leaion, ur oulyaciiHaestio" iuappreola' '
by our a^nsiis ; but it va^ inorH painful than tLid situplH leaioii wontd have me
out) suppose. I call it uuurnliiiu arClirilU or eiaggeratud suoailjilitj of tlie kuuu.

soo

DISEASES or THE ARTICULATIONS,

ffasion aymptomatic of an inflammatory conflitioii. Now, althnuijh
we have not often had occasion to make the autnpsy of patients dead
with hydrarthrosis, yet, in the rare cases where this occasion has been
presented, an injection of the aynoviwl Tiiembrane has been found,
representing Bonnet's congestive form, of which I have already spoken,
with a very slight thickening; and as in the other side, the clinic
teaches ua that most patients affected with effusion in a single knee
have at the same time some functional symptoms which can be ex-
plained by inflammation, I prefer to make use of the word arthritis,
which indicates that in my opinion it is an inflammatory disease.

I Bought, in our patient, if there was at the outer and upper part of
the articulation one of those indurated nodules which Marjolin anrl
Malgaigne pointed out as sometimes accompanying hydrarthrosis,
whiuh may be attributed to a partial thickening of the synovial mem-
brane. But I did not find these nodules, although I have found them
upon other subjects,

I have just touched upon another point of the anatomical diagnosis.
M^hat are the lessons of this arthritis with effusiou? I assure you
that the clinic has given no physical sign which could indicate any.
If these lesions exist, and I do not doubt it, they ought to h« in the
synovial membrane, for that is the only way of understanding the effu-
sion. But it does not seem to be thickened, neither as it is in phii^tic
arthritis, nor as it 11 in fungoid arthritis. I do not deny a slight
augmentation of volume like that which Sometimes accompanies con-
gestion, I am disposed especially to admit this augmentation in the
synovial fringes corresponding to the intercondytoid space; but the
lesion is not sufficiently marked to be felt through the skin. I believe
much more in the existence of injection or hyperjemia like that
which was fouud in the autopsies of Dupuytren and others, and I
believe it, not because it is proved to me by physical signs, but because
the effusion and the functional symptoms are those of an arthritis, ami
because I do not know any other lesion than congestion or hyperemia
which could explain them.

But what must we think of the other constitutent parts of the articu-
lation? I admit that I fear some nutritive trouble in the cartilages;
for there is such a solidarity between them and the synovial mem-
brane, that they end habitually by becoming altered when the other
has been diseased for some time. Still, there is as yet no physic-al sign
which authorizes me to affirm the existence of a lesion in that
quarter. The same is true of the ligaments; if they were softened,
and they sometimes are in hydrarthrosis either by excessive distension,
or, which seems to me more common, by a concomitant trouble of nu-
trition, we should have lateral mobility ; hut I satisfied myself that it
did not exist. Moreover, they are not rigid, for all corainunicated
movements are executed almost as they are normally. Voluntary
movements also take place, but they are limited by the pain and not
by an appreciable material modification of the means of union.

As to the bones, 1 have noticed nothing in the femur and tibia;
the first, in particular, has not shown that hyperostosiu swelling tvith
whioh we were struck in uartuin plastic arthrites (see p. 295). X

CHRONIC ABTHRITI3 OF THE KN'EE.

SOL J

point out to you only a very markeil transverse enlargement of the"!
piilella. We meaaurerl it with a cnmpaaa, and found it nearly half ani*
inch larger than that of the opposite side. This enlargement of the I
patella in hydrarthrosis was pointed out long ago; but its origin and f
its fligiiification were not explained. For me, its origin is ptill in aa J
bypertrophying osteitis, of the kind of which I have ao often spokenij
to you. Instead of afiecting the fomur and tibia in a manner appre^i
oiable during life, this osteitis is confined to the patella, a peculiarity*
which is utterly inexplicable. Its signification, however, appears tO'J
me to be the same aa that of femoral hyperostosis in other arthritec,!
that is to say, since condensing osteitis appears habitually in patientftfl
who are not scrofulous and consequently not predisposed to I'ungoiclM
and suppurating arthritis, the appearance of hyperostosis of the patella ll
would be a reason to dismiss any fear of the occurrence of the latter^ "
even if some physical signs should have given rise to it.

To recapitulate, gentlemen: in making the diagnosis, (/ro;)m'cff7ar(Art-
ft's, I presume that we have to deal especially with a rebellious hy-
pertemia or congestion of the pynovial membrane, and if I do not uss-]
the expression congestive arthritis, it is because this expression does I
not Bufiiciently indicate one of the principal things, the abundance of 1
the liquid. And as congestive arthritis may take place without effu-
sion, and as the latter, when it does exist, htis a bearing upon the prog-
iiosis and treatment, it is better to use an expression which indicates J
its presence.

Aa for the etiological diagnosis, T told you a moment ago that it ii
a rheumatic disease. At least, we can give no other explanation than 1
that. It is an insoluble problem, that of knowing why this same
general cause is marked by eft'ects which are so varied, sometimes a
plastic arthritis without much effusion, sometimes a simple congestive J
arthritis, sometimes a congestive arthritis with effusion, and at othei
times, as you will see, the dry form. But we have nothing better to 1
substitute for this etiology, and we must keep it because it indicates j
the use of certain curative and prophylactic measures. I

Pro_97KWM.— What preoccupies me above all in this patient, is ihei
probability that his afiectiou will last a long time, and the possibility of I
a relapse after it has been cured. I have but little fear of its termi--!
nating by suppuration, because hydrarthrosis, when not symptomatio 1
of a fungoid synovitis, almost never ends this way. Nor do I fear |
complete anchylosis, because exudations and false membranes do not I
exist, or exist in too small quantity to bring about this result. More- ]
over, even if there were false membranes disposed to form adhes
the interposed liquid would prevent it. If anchylosis should here-
aPler occur, it would be incomplete and due to rigidity of the synovial
membrane following a slight thickening which may now exist, although
the~ physical signs do not clearly show it. But it is probable that
auch an anchylosis would be temporary, and that resolution would be
obtained. It is possible that, if the disease resists our treatment or
reappears a certain number of times, dry arthritis may be substituted i
for the dropsical one. For it is difficult for the phlegmasia to con-
tinue without extending from the synovial membrane to the cartilagea.

802 DISEASES OF THE ARTICULATIONS.

Alteration of the latter leads sooner or later to their destruction, and
when they are once destroyed, if the articulation does not become an-
chylosed, it is inevitably destined to dry arthritis.

Treatment, — We must distinguish between the curative and the
prophylactic treatment.

1st. Curative treatment. — Two indications are to be nnet : to get rid
of the synovial congestion, and to get rid of the effusion. .

The first needs absolute rest in the horizontal posture; to that we
have added since the beginning elastic compression by means of the
cotton batting dressing. At the end of a week, not having obtained
any diminution, we applied two blisters, and four days later, two others.
We interrupted the compression the day the blisters were applied,
and renewed it as soon as the epidermis had been opened. Only one
purge has been given.

These measures have been sufficient in a certain number of cases,
and seemed to act at the same time against the congestion, the start-
ing point of the disease, and against the eflfusion. The patients were
able to leave us at the end of five or six weeks, walking quite freely,
and having no longer any swelling or fluctuation. In others we
needed from six to eight weeks, at the end of which the cure, although
temporary, was obtained. In others again, pain on motion no longer
existed at the end of this time; the effusion was diminished, but was
still quite large. As confinement to the bed fatigued and weakened
the patients, I let them get up and walk with crutches, on the condition
of always keeping the cotton dressing applied to the foot, leg, and
lower half of the thigh. Sometimes I wrapped a band of vulcanized
rubber about the outer bandage so as to insure compression.

In this case, after confinement to the bed for four weeks, blisters,
and compression, although the sensibility seemed to be diminished,
we still found considerable effusion. It is then one of the cases in
which we have to turn to the second indication, address ourselves to
the effusion itself. I met this indication this morning at the bedside
of the patient. I punctured with a very fine trocar and withdrew
the liquid by means of an aspirating syringe, making it flow into a
vessel in which a vacuum had been made before the faucet communi-
cating with the canula of the trocar had been opened. You saw that
the liquid escaped very freely, and that I avoided making any pres-
sure upon the joint under the pretext of favouring the flow. The evacu-
ation ended, I took care to close the small opening with collodion and
to replace the cotton bandage. There were about five ounces of liquid.
It was sticky, yellowish, and although it did not offer the troubled or
gray tint which indicates the admixture of a certain quantity of pus,
yet we found a few lecuocytes in it. Still I am not disturbed by this
fact, because normal synovia always contains a certain number of these
elements, and their augmentation after a slight inflammation by no
means indicates a tendency to suppuration, as we understand it in
surgery.

But after this puncture, and if we continue the compression, will
the patient get well? That depends upon the cause, doubtful for me,
of the effusion. There is no doubt but that its starling point was an

CHRONIC ABTHRITIS OF THE KNEE,

excess oFsecretion. It then tjontinaed because absorption was inan:
cient. If now the synovia] membrane is so happily mollified that
equilibrium maybe re established between the secretory and absorbini
functions, the puncture will succeed. But if it remains vascularizetl
its secretory function exaggerated, and its absorbing power cJimin
ished, the liquid will he reproduced and not absorbed. It is bi
no symptom can enlighten me on this puint that I cannot determine-
the consequences of our operation.

If the same quantity of liquid is reproduced, what shall we do?l
Until recently, we rarely punctured the joints, because we feared coa.'
secutive suppuration. But now the facta published bj M. Dieulafoy,
and those that I have myselFobserved, authorize us to believe that capit
lary puncture with aspiration does not expose to this danger. There-J
fore I should be willing to make a second and even a third punctur^a
if, after two new blisters and the continuation of the conipreaaioitl
bandage, the liquid was not reabsorbed.

Perhaps alao in this case I shall have recourse to actual cautery.fl
Some surgeons claim to have obtained very good results by thi»r
operation, the effect of which ia to produce a strong revulsion and
cause rigid cicatrices which oppose distension by a new effusion.

If, finally, after five or six months of treatment, I should not have!
Bucceeded, which I do not think is very probable, I shall allow thel
patifent to walk while wearing the compressive bandage. Perhaps al
little later, and I have seen examples of it, the effusion will end byl
disappearing and not being reproduced, leaving the articulation its j
shape and functions.

Perhaps also, the cartilages having disappeared and the synovial
membrane having become rigid, the bydrarthrosia may be transformed
into an incurable dry arthritis.

If then, after waiting a few months, the effusion persists, or if after
having disappeared once or twice it is reproduced ; it^ above all, I
think I see a tendenoy towards a termination by dry arthritis, I shall
propose an injection of iodine, one-third of the tincture of iodine in
two-thirds of distilled water. This operation, which was recommended ■
and performed thirty years ago by Velpeau and Bonnet (de Lyon), ia 1
now rarely practised. I have employed it only twice. Why this '
disfavour? Because the injection is followed by a very acute arthritis.
In some cases, notably in one of Velpeau's, and in one of Aug; BtSrard's
of which I was a witness, this arthritis ended in suppuration, purulent
infection, and death. In other cases, and this is what happened in
my two patients, the arthritis thus provoked remained plastic and
ended in complete anchylosis. I believe we cannot count upon a
better result, especially upon the anhatitution for the dropsical arthritis
of an arthritis capable of terminating by perleut resolution with pre-
servation of movements, and it is because we cannot count upon this
that we should not make haste to advise the injection of iodine. I
should however advise it if the relaxation of the ligaments and c
mencingcrepitation mi\de rae foreseedry arthritis, for the provocation .
of an acute arthritis is leas to be regretted. I think indeed that witUll

301 DISEASES OP THE ARTICULATIONS.

care, and especially by means of immobility and proper compression,
suf)pu ration could probably be prevented.

2(1. Prophylactic treatment. — If we obtain, as I hope, resolution of
the effusion and of the congestive arthritis, there will be two indica-
tions to meet. The first is that of combating the rheumatic cause,
by advising the patient to occupy a dry room which faces the south;
to avoid getting chilled, to wear flannel, and to pass, if possible, one
or two seasons at one of the thermal springs which I have already
mentioned, in short the advice which we usually give rheumatic pa-
tients. The second is that of maintaining constantly, while walking
or standing, a certain compression upon the knee by means of a laced
dog-skin or canvas knee-cap. These appliances are often troublesome
bacause they are too tight, or useless because not tight enough. Care-
ful and intelligent patients find it better to wear a flannel band two
and a half inches wide and about three yards long, which they apply
ti«^htly enough to make the necessary compression without being
thereby incommoded.

LECTURE XXXVII.

CHRONIC ARTHRITES OF THE KNEE, Continued.— FUNGOID ARTHRITIS OR

WHITE SWELLING.

Non-suppurative white swelling of the left knee in a young man 20 years old — Physi-
cal and functional symptoms — Muscular atrophy — Absence of hyperostosis — In-
crease of local heat — Anatomical diagnosis — Undoubted fungoid transformation
of the synovial membrane and the ligaments — Presumed lesions of the diarthro-
dial cartilages and the ligaments — Rarefying osteitis or simple rarefaction, and
fatty condition of the cancellous tissue — Etiological diagnosis — Course, termina-
tion, and prognosis ; tendency to suppuration ; very little tendency to anchylosis
— Treatment — Indication to favour anchylosis — Cotton batting apparatus, im-
movable fenestrated apparatus — General treatment.

Gentlemen : The patient who was admitted yesterday, No. 4, ward
Sainte Vierge, and who resembles two others who have been here for
several months, is a young man 20 years old, a shoemaker, who says
his left knee has been affected for about a year. As it caused him
no pain, and only a little difficulty in moving, he has thus far done
nothing for it. But a week ago, after having walked the day before
a little more than usual, he suffered pain, was unable to walk, and
was obliged to enter the hospital.

You are at first struck with his puny look. He is small, beardless,
pale, and with thin muscles. We find the scars of no abscesses on
the neck, but he told us that his childhood had been sickly, and that
several times his eyes had been inflamed and there had been a dis-
charge from his ears. Although he has had no haemoptysis he is

CHEONIC ARTHBITIS OF THE KNEE,

305'J

Biibject to colda. His father is still living, but he thinks his motliei
died of some disease of the chest. lie has two sisters who, he says^
are pretty well, but ho haa lost two brothers, one in infancy, thW'
Other at the age of 18. In short, his constitution is lymphatic, his
antecedents and those of his family show a predisposition to tuberculi-
zation.

As for his knee, it presents physical symptoms and functional
symptoms.

Physical symptoms. — The knee is completely extended, uniformly,
swollen, rounded; ihe lateral depressions on each side of the patella
are effaced. Placing the fingers on the outer side, a little above thai
auparior tibio-fihular articulation, I feel a lobe a little distinct from
the rest. The swelling is flabby ; at certain points it yields a senaa
tion similar to fluctuation. But, if grasping with both hands the lat-
eral portions of the knee, I press the patella backwards with my fore-
finger, I find that it remains immovable, that it is not pushed towards
the condyles of the femur, as it is in hydrarthrosis, and that the fingers
placed upon the sides are not raised by the liquid. If we seek fluctu-
ation by placing two fingers on the outer and two on the inner side,
we do not find it. There is then no liquid in ihe synovial cavity
ifthereisany it is not abundant enough to give fluctuation. These
tion of this kind which is felt here and there superficially ia not furnished'
by an intra-arlicular liquid. It is not resistent and not elastic, and '
caused rather by very soft tissues tli-an by a collection of liquid. F
more certainty I pricked two of these soft points with a pin, and saw
no liquid flow except a little blood which evidently came from the
prick. When we compare the two thighs we are struck with the
difference in their size. The muscles of the left one are evidently
atrophied ; so too are those of the calf of the leg, but to a little less
degree. This atrophy, which isconstant after articular diseases of long
duration, seems to me to be due, like that which we find after fractures
(page 71), to the irregular distribution of the nutritive material between
the synovial merabruue which uses more and the muscles which receive
leaa. I felt deeply to see if the femur was swollen, it did not seem to
be, and, indeed, we have here a chronic disease, in a feeble patient,
whose constitution, as I have already told you, does not predispose to
general or very extensive hypertrophying osteitis.

As functional symptoms. I showed you an elevation of temperature,
easily recognized by placing the palm of the hand alternately upoa
the two knees, I did not make an examination hero with the ther-
mometer, but I have done so upon others who showed the same differ-
ence of temperature, and found from two to five and a hall degrees'
(Fahr.) of diflarence. When at rest, the articulation ia not constantly
painful ; but you heard the patient say that be often felt, especially at
night, shooting and throbbing pains, and, like most patients who suSer
in the knee, he indicated the inner side as the principal seat of the
pains. When asked to flex and extend the articulation, he was nn^
able to do it on account of the pain, I then myself communicated
these movements and showed that they were possible; I farther found N
abnormal lateral movements, without crepitation. Ko general sym]

DISKASEB OF THE ABTICIILATIONS.

toms, no fever. The chest was carefully examineil and showed no
physical sign of tuberculization, notwilbstauding the fears excited on
this point by his antecedents,

Anatomica} diagmsis. — We are again authorized here to admit the
existence of an arthrilia, since it is a disease with swelling, pain, and
heat ; we may say that this arthritis is chronic, for it began a year ago,
and is not accompanied by fever. We may add, on account of the
pains which have recently occurred, that it is a chronic arthritis with
a subacute inflammatory attack.

We have now to determine by what lesions and by what tendencies
this chronic arthritis diflors from tboae of which I have already
spoken, and those of which I shall hereafter have to speak.

Among these lesions there is one of which we have no doubt, that
of the synovial membrane. It consists in a thick flabby swelling,
former! of a grayish tissue, infiltrated with serosity, and moderately vas-
cular, the appearance of which, on section, recalls that of a thin jelly.
In its chemical composition there is much fibrine according to Bonnet,
mucine according to Paquet; and in its histological composition we
find, together with molecular granulations, fusiform and stellate cells
and amorphous matter. This singular lesion is that which, sine?
Reimar, has been known m fuvgoid subslnnce or fungoid syiigvila.^
It may be considered aa a profound modification, not of limited por-
tions of, but of the entire, synovial membrane.

When the synovial membrane of an articulation has become fungoid
we often liod an eflusion of liquid into its cavity ; in this case I have
found none. If there is any, it ia not abundant, and is not purulent.
For purulency would be accompanied by a notable increase in the
quantity, and consequcutly by a fluctuation which would be easily
appreciable.

There is another lesion of which we have scarcely any more doubt.
That is the lack of resistanue in the ligaments due to their traosfor-
mation into a similar fungoid substance. Lateral mobility, in our
patient, and the frequency of autopsies in which we have found the
fungoid condition of the ligaments coinciding with that of the synovial
membrane, arc the reasons which authorize me to admit the existence
of these anatomical disorders.

Other lesions should he suspected, but they are not indicated, like
the preceding ones, by physical signs. They effect the diarthrodial
cartilages and the bones. They exist, do not doubt it; for anatomo-
pathological studies have abundantly proveii that the articular syno-
vial membranes do not become fungoid, without, at the same lime,
the ligaments, cartilages, and bones being altered, and I have told you
that although I have no anatomical documents to prove it, I admit-
ted the same thing in plastic arthritis which had become chronic, and
in dropsical arthritis. There is such a physiological solidarity among
all the constituent parts of an artieul.ition that the chief one of them,
the synovia! membrane, cannot long be troubled in its nutrition, with-
out the nutrition of tlie others being modified and causing the lesions
peculiar to them.

' Substance fongnenai;, 9;iiocil« fungiieuae. ^^^^^^^h

■ CHRONIC ARTHRITIS OF THE KNEE.

Here then I do not see, and I appreciate by no special
lesions of the diartbrodial cartilages. But ii ~
lar affection has lasted a year, for me to
believe in their existence. What I do
not know is the degree which they have
reached. Ts it only the first degree, that
ia which the lesion is purely histologiuul
and consists, as Dra. Ranvier and Paquet*
have said, in fatty degeneration of the
superficial cells, and then proliferation of
the deep cells of the cartilage? Is it a
more advanced period, that in which the
diarthrodial cartilages present the velvety
aspect, that is, an uneven surface formed
by a mass of fibrous prolongations instead
of the normal smooth and polished sur-
face? Is it not another lesion still more
advanced, in consequence of which the
cartilages, losing their means of union
with the bones, strip off and fall into the ar- i
ticular cavity ? Do those solutions of con-
tinuity described by Brodie under the
name of ulcerations, exist on their free
surface with or without decortication?
Finally, has that absorption commenced
which is so common in these organs and ti
which accompanies or follows the preced- J
ing lesions, — isit already quite advanced?

To these questions, and the same ones are to he asked for the fibro^
cartilages, I do not and cannot reply positively. One single thing is
unquestionable: the cartilages are injured and will become more and
more so as the a&ectlon grows older, until they finally disappear,
either by total absorption, or by partial absorption followed by the
'detachment of some portions, like that of the sequestra of DecrosiSjJ
into the articular cavity.

Allow me to tel! you in passing that lesions of the cartilages are!
about the same in all diseusesof the joints. They are always destrua-r
lions which are more or less comparable to ulcerations, but wbiobJ
differ from them essentially by the absence of concomitant suppura../
tion ; ihey are velvety change, denudation of the bone, and finally*
absorption. Modern researches have shown that the histologioalj
lesions of the beginning are variable, but the consecutive lesions araa
not. It seems that when the cells and their capsules are once deprived! I
of their normal conditions and destroyed, the cartilage is always siir'
larly affected and troubled in its nutrition, and that this trouble leads I
to a total or partial destruction. This lesion is the more important I
because it is irreparable and baa cost the articulation one of the capital
conditions of its ability to perform its functions. It ia posi^ible thatfl
the limited ulcerations heal, like those found in tarsalgia; but eiclti

' Pnqiltit, Th&ie da P&ris, ISUT.

aive destructions, and still more those wbicli involve the whole car-
lage, do not heal.

The same certainties and the same doubts esiat for the bones aa
for the curtilages. I am sure that the bones are injured, becauae
autopsies have often shown that they always become injured to a oer-
taiti degree in fungoid synovitis. I am sure that their cancellous tissue
not suppurated, for we have neither the external fistulous abscesses
the articular suppuration which would be the consequence of this
suppuration, I suppose, fur it is very common, that the compact sub-
cartilaginous layer ia wholly or in part destroyed and replaced by
vegetations which are continuous with those of the synovial mem-
brane, that the cells of the cancellous tissue have become enlarged,
and their trabeculi friigile, so that a probe or the finger-nail would
penetrate them very easily. Are these spaces filled with a soft, gela-
tiniform, grayish substance similar to the vegetations, and consti-
tuting the first period of rarefying osteitis? are they|Ou the contrary,
filled with that red and very vascular substance which made Bonnet
use the name splenisalion, or are they filled with fat and not vascular,
which would constitute Cruveilhier's fatty condition, and a variety of
I'arefaction, rarefaction without osteitis? Are there not here and
there very vascular points beside others thai are hypertrophiert and
eburnated, which would belong to the lesion described by N^latoa
under the name of tubercular infiltration, and which for me constitute
a variety of osteitis of the cancellous tissue, an osteitis condensing
and necrotic in some places, rarefying in others? I am not enlightened
upon all these points ; and .'since we have to deal only with presump-
tions I shall not explain all these lesions, which I shall, moreover,
have occasion to show you whenever we dissect artioulationa alieeted
with white swelling, either after amputation or after death.

What I wish to fix to-day in your minds Is that we have no doubt
of the fungoid condition of the synovial membrane in our patient, and
that, from the moment when this fungoid condition becomes incon-
testable, all the other constituent parUs, including the hones, are altered
to one of the degrees and in one of the forms indicated by pathological '
anatomy, although we are not perfectly informed as to the estent of
these alterations.

There is, however, a point which should detain me a moment.
Our authors have spoken of white swellings, some of which begin in the
soft parts, others in the bones. I presume thiit in this case the lesions
began in the synovial membrane; for the patient has not had from
the beginning those pains which denote deep osteitis of the cancellous
tissue, and he has not the abscesses by which this osteitis would un-
doubtedly have ended if the lesion had begun with it. Retain, if you
choose, a few doubts as to the starting point, but have none as to
another which is capital at this moment. It' there ia osteitis it has not
suppurated, it is not in that condition of rarefaction with suppuration
in the meshes of the cancellous tissue which, for me, constitutes caries;'

' Wa flra not itU agreed upon the fligniflaatioii of the word caries ; in tny opinion
it onglit to be employed to uxprtiss tlia^'H tiro tilings: nrnrfiug iufiam!
BDppuratioD uf tliii uauaelloaa lissae of tha bones.

ai
tn

CHRONIC ARTHRITIS OP THE KNEE.

nor is it in that state of partial ebuniation with peripheral auppura<
tion which constitutes the interstitial necrosis of the cancellous tissue]
r of which I spoke a moment ago, and of which I recently ahowed youj
mple.
lEliological diagnosis. — We make that easily by means of the infor^J
I tnation furnished by observation of a large number of patients. The,*
synovial membrane of tlie knee becomes fungoid under the influeuc
of that great general cause which we call scrofula, that which gives^
rise to either ganglionary or pulmonary tuberculosis. The existence^

■ of this cause in oar patient is indicated by his constitution and his

■ femily antecedents. But it seems to have exerted no injurious in-
^ifluence upon the other articulations or upon other organs, especially
^Kthe lungs. We hope that it will not aSect them; but we can have
HrtK) certainty upon this point.
B Course, lermination, prognosis. — Do not forget, gentlemen, the seriom^
^Reonsequence which results from our diagnosis, fungoid arthritis o^

■ ■white swelling. It is the tendency to articular suppuration after a
■"longer or shorter time. In other words, if the patient ia not properlft

■ treated, or if the treatment does not succeeil, this synovitis will termi4
~ nate soma day by suppuration, with or without suppuration of th^

accompanying osteitis. The abscesses will open and become fistulouaa
perhaps, after an intercurrent acute attack, so much pus will suddenljd
form within the articular cavity that the synovial membrane wilt"

! rupture in its upper cul-de-sac and let a considerable quantity of
this pus pass under the deep muaciea of the thigh, an example of
which I have lately shown you. In any case the prolonged suppura-
tion, the inaction to which the patient will be condemned, the necea-
aary confinement to the hospital may lead sooner or later to hecticity^i
or to the tuberculosis to which, as you know, his constitution already
predisposes him. Again, the difficult passage of the pus from thit
Wge anfractuous cavity, and its consequent stagnation and decomposi"
tion, might cause a putrid infection and hasten hecticity. A momentr.
then, will undoubtedly arrive, when, to preserve the patient from ons]!
or the other of these terminations, amputation of the thigh or reaectioiwl
will be the only resource.

In case, however, hecticity should not occur, and if the patientfH
should resist articular suppuration, this wliite swelling might end by

(anchylosis, the tibia and femur stripped of their diarlhrodiai cartilages,
uniting by a process analogous to that of the callus. It would then
be an anohylosia by fusion after suppuration. I admit that I do nut
^unt much upon such a result. But I should count more upon it j
if the patient was younger, if he was a child, if he was in better hy-,-^
gienic conditions.
Nevertheless, if tardy suppuration is the natural termination oftl
disease, and if it establishes a capital difference between the fungoid
arthritis with which we are now occupied, the plastic arthritis c'
which I have already sj)oken, and the dry arthrilia of which I a'
I soon speak, yet it is not inevitable, and you should know that i
Itherapeuticiil efforts should be directed to prevent it.

What will be the course and the termination of the disease if .^jig

810 DISBA3E3 OF THE ARTICULATIONS.

puration does not occur? It will not ba the return to the normal ana-
tomical and physiological condition, I do not mean that this reium
is absolutely impossible; it may be that it has taken place in a very
few children, but I do not believe that it has in adolescents and adults,
and above all in subjects who belong, as this one does, to the poor
class and are unable to obtain all the hygienic resources capable of
bringing about this very rare result — cure of a while swelling of the
knee with preservation of shape and movements.

That is due, gentlemen, to the anatomical and physiological modifi-
cations which take place in white swelling. This synovial membrane
transformed into fungoid tissue is too profoundly altered to be able
to recover its normal structure. It no longer has any epithelium or
connective tissue; all the abnormal prodnots which infiltrated it, the
seroaity, the fusiform and other embryonal cells would have to dis-
appear and be transformed again into connective tissue covered with
pavement epithelium, and the nece.'^aary condition of such a change
would be that the state of the organism under the influence of which
the lesion occurred should first disappear. Certainly all that is not
impossible, but yon must admit that it is very difficult. Bonnet
formulated it exactly when he said; "Thesynovial fungoid tissue ia
the product of a bad nutrition, and it has no tendency to be reabsorbed."
I add that it has a very much greater one to suppurate.

What happens sometimes is a very slow transformation of the
synovial membrane into a more or less fibrous, inextensible, and
rigid tissue. It is a sort of substitution of anchy losing plastic arthri-
tis for fungoid arthritis threatened with suppuration. The anchylosis
also may be incomplete, without bony fusion, and due merely to this
fibrous transformation of the aynuvial membrane; or it may be com-
plete, and by fusion, as I told you that took place sometimes after
preliminary suppuration.

But fusion is loo often prevented, either by a displacement of the
articular surfaces which abandon one another in consequence of the
softening of the ligaments and form what is called spontaneous dis-
location, or by the nature itself of the osteitis which is not sufficiently
plastic in these subjects to furnish the materials for a new bony forma-
tion.

This difficulty of eaiabiishing a complete anchylosis when there
has been no suppuration is unfortunate, for this result would be very
desirable after a white swelling of the knee. When this latter apfmara
to terminate in a fibrous transformation and a lack of extensibility of
the synovia! membrane with preservation of motion, there ia always
reason to fear the persistence of some fungoid points and the return
of the suppurative tendency. When the bones are united and con-
sequently a sprain is no longer possible this return is less to be feared,
and the synovial, aided by the immobility, completes little by little
its fibrous transformation.

Prog^iosis. — It is grave and may, in accordance with what I have
just said, be slated as follows : A disease of long duration tending to-
wards suppuration, and leading almost inevitably to the destruction
of the joint, either because mutilation is reudered necessary by bee-

CHRONIC ARTHRITia OF THE KNEB,

-ticity and threatened death, or hecaose anchyloaia is established;
disease which further threatens to be complicated, one day or anotheii
[by oulmonary tiiberciiloaia.

TTeatmejit. — You have already comprehended the indications to t
met : to prevent suppuration ; to favour the formation of an anchylosis
(since we can hope for nothing better; to prevent tuberculizatioavj
JThe means which we have at our disposal to meet these indicatione
tave this advantage, that if hy chance the patient is in the very ex-
ceptional category of those who may get well by the return of the
synovial membrane to its normal anatomical character, they favour j
also this return, ■

Some of these measures are local, others general. jl

A. Local measures. — I told you that we were in presence nf one ofa

» those fresh inflammatory attaclia to which patients affected with white
swelling are exposed. This must first be treated by rest in a wire
splint and pouliices, sprinkled with laudanum if neoesaary. If the
articulation is bent, aa aometimea happens, although it ia not the caa$ f
here, it must be straightened.

As soon aa the infl:immatory attack ia over, rest and cornpressioiy
will be the principal local measures to employ. The patient will rmL
jffiain in bed, and 1 shall apply the couon wadding bandage, whioM
described when speaking of hydrarthrosis, and with which we c&bP
ke forcible compression without, however, interfering with the cirM
culation. You know that for this purpose we wrap the limb ii
thiiik layer of wadding, about four iiichea, and roll a band very tlghiljf>B
about it. It ia not necessary at first to envelop the foot, I shall dam
that a few days later if it becomes cedemalous. This bandage wilt ba ■'
fl«newed every six or seven daya and we shall see if the swelling and
tocal heat diminish, if an effuaion of liquid takes place into the artica-
iilation, or if by chance, as sometimes happens, an abscess forma out-
■eide the joints, in the external layers of the synovial membrane, aaj
Blbscesa belonging in the category of those which Gerdy "called ab;
flcessea by proximity,"

I After six or seven weeks if no infiammation remains, if no coritfl
aidcrable amount of hydrarthrosis has been superadded, if we find noil
.tendency to the formation of abscesses by proximity about the uppepfl
«!!ul-(le aae, where they appear most frequently, I shall apply an im? ■
movable apparatu.s, made with dextrine or silicate of potash, aftepj
Aaving wrapped the limb in wadding. If there should be any ten-B
■fleucy to flexion of the knee I would place inside the apparatus, atM

frou have seen me do several limes, a posterior wooden splint of thqa
ength which we use for fractures of the leg. This precaution woulcl*
be useless in this case, for the knee is perfectly extended. My objaoBj
in substituting the immovable fur the movable wadding apparatus
frould be to allow the patient to walk. For confinement to the bed^l
rwhieh ia an excellent means to insure immobility of the knee, has th^l
'inconvenience, when prolonged for a long time, and especially whenT
subject is obliged to live in the midst of other patients, of weaken-
and favouring thedevelopment, already soimminenl, of tuber-
ulosis. With the immovable apparatus the patient will be able,

■the a

312 DISEASES OF THE ARTICULATIONS.

rerti-

without any danger of the articulation malcing any injuriona
nients, and much more anfely in tbia respect than if the limb was lo
the cotton bandage, to walk with crutclies, go into the garden, breathe
a better air, perhaps will even be able to leave us and return to his
family in the country, Anotber advantage of the immovable appara-
tus is that it can remain in place three or four months without tha
intervention of the surgeon unless new pains and indammatioa should
occur.

There are patients in whom the immovable apparatus does not pre-
vent pain during walking, whether it be that this pain results from
some imperceptible movements of the joint, or whether it is due to
the pressure of the articular surfaces against one another in the verti-
cal posture. Of course in such cases rest in bed must be ordered,
continued until new attempts shall have shown that the patient
walk withoMt pain.

It is not impossible also, aa I intimated a moment ago, that
walking for a few weeks the patient may be taken with Fresh paiii%
without apparent cause, or after fatigue, or even on account of a
change in the weather. For I should tell you, in passing, that lym-
phatic patients affected with white swelling are not exempt from
rheumatism, and this latter icfluence, when it exists, may be the
cause of a return of a pain in the affected joint. In such a case the
indication is the same, to keep the patient again in bed for a few
weeks until the sensibility disappears.

The objection has been made against immovable apparatu.ses that
they hide the affected region and prevent us from observing the phy-
sical signs and making use of other local remedies, especially the
revulsives. You know how I reply to this objection : when the appa-
ratus has been dry for some time, and T am satisfied that it is stiff
enough to meet the indication of immobility, I cut out a circular cap
about ten inches in diameter over the anterior part of the knee, I then
remove enough cotton to uncover the knee, examine the sides and
front of the joint, put on fresh cotton, put on the cap, and bind it
down tightly by means of an ordinary band, so as to combine the ad-
vantages of compression with those of immobility.

I have long used this kind of apparatus, to which I gave the name
immovable fenestrated ; we often have in our wards patients who wear
it, and from time to time you see others who having returned to their
families come back to see us, either to tell us how they are, or to ask
if their bandage needs to be changed, for they have to be renewed
every three or four months to prevent their deterioration.

Whatever may be the usefulness of this dressing, it does not pre-
vent tha long duration of the disease, nor does it inevitably prevent
suppuration. Among the old patients who came back to see ua this
year (1872) I showed you a stout, young man 2l3 years old, whom I
began to treat at the Hopital de la Piti^ in 186d, upon whom I have
placed the immovable iisneBtrated apparatus twelve times for a white
swelling of the left knee, who has sometimes been able to walk for
several months with a cane, and .sometimes has been laid up for
several weeks with sharp pains, the seat of which seemed to me to bs

CHEONIO AETHEITI3 OF THE KNEK.

in tha tibia rather than in the synovial membrane, who, however, h:

had neither articular nor ossifluent abscesses, and who, in short, has

reached the complete anchylosis which we sought and hoped for, I

showed you also a young girl 23 years old, in whom I placed ten

times, in the space of five years, the immovable fenestrated apparfitiis,

rinade sometimes with plaster, Bometimes with dextrine, sometimes

Lvith silicate of potash, and who, notwithstanding an incomplete spon-

Bt&neous dislocation and slight fiexion of the knee, has also reached

iDchylosis.

On the other hand yon doubtless remember two of our patients in

jrhom, notwithstanding the use of the apparatus for two and three

lyears, suppuration and hecticity occurred and necessitated in one re-

' eection of the knee, in the other amputation of the thigh, both of

whiuh were successful.

I shall then place upon our present patient the immovable feni
trated apparatus, I shall open the fenestra every other day to apply,
tincture of iodine, and I shall take care each time to renew the appa '
rntus and the compression in the way 1 indicated. If I always find',
the knee hot, if I hear of pains which oblige the patient again to keep'
bia bed, I shall make through the fenestra, as you saw me do two
weeks ago to the patient in No, tS, a punctate Cfiuteriaation. If an
abundant effusion forms I shall apply blisters, still without removing
the bandage. Finally, the apparatus will be removed every three or

'O ^^

tn
ig

JfouT months, and each time I shall see if the anchylosis which I desir$.^H
Js forming. We ahull continue thus for as many years as may b6.^^B
irecessary. Of course if suppuration should set in and should opetl^^|
'directly outwards or through the deep muscular interstices, and hec-
ticity should occur, I should consider, after a fresh examination of
the chest and determination of its proper condition, the question of

» amputation or resection, a question which I cannot now discuss. ^^

B. General treatment. — It ought to consist in the use of all thd.^^|
tonics which we have at our disposal in the hospital : cod-liver oi]|^H
iSntiscorbutie syrup, quinine, wine, iron, strengthening nourishinentj^^l

and moderate exercise according to the conditions which I indicated.

If he was a private patient and in a social position which permitted

it, we should add the much more powerful resources of a visit to the

I country, to the seaside, to the bromine and iodine thermal springs,

sspeoially those of Salins,' Perhaps then we should be more likely

I to prevent suppuration and obtain anchylosis. I also repeat that

if it was a child, we might exceptionally, by the combined

leae local and general measures, obtain a cure with ]

he movements,

iraad Fardel's Diot, d(<s EaUK minerales, Lebrel and Lefort, Par

H 814

DISEASES OF THE ARTICCLATIONS.

LECTURE XXXVTII.
DRY ARTHRITIS OF THE KN'EE.

I, Ca^e ni a, patient ufldaled with dry srtliritia of bntli kuees. II. On the laFt Iba
flrthiitis is at Ilie s»me time dropsical aiirl dorormlng, Icnouk- kneed — ADatomiotl
exiilHnalion of the Bymplnins hy synoTial oon^estion, probable wparing awaj
□f ttie oartllages, absorption, ariec rari!<faDtion, of the cancellous tissne of ttia
Olilar ooudjle of Ilia femur— Dlti mate oonrae of ths diseaae ; its inonrabilily—
The name dry artlirilis is llie only oiiL' we liava to espresa this group of aymp-
toiDS. III. In llie right koae, considerable increnae in size of Ihe end of tlie
femnr, very marked lateral mobility, loud craokling — Sabluiation of liie tibU
—Explanation of these symptoms by the fnrmatinn of osteophytes, iJeatruplion
of the ligamanla, abarnatiou of the arlicnlac anrfaoen. IV. Cases of other
patients affvcteil wiib dry arthritis of the knaa — Principal varieties of this dia-

Gestlbmen: I. We have at No. 25, ward Ste. Vierge, a man 58
years old, whom we shall not keep very long, although both his bneea
are diseased, for we eannot cure him. Hs has been suffering for
seven years, without apparent cause, or at least without bia being able
to attribute it to any traumatic lesion. He only knows that his left
knee has often been swollen, and that he has been treated for dropsy
of it. The right one does not appear to have been the seat of a simi-
lar effusion, but the patient has also auffared in it almost constantly,
sometimes a little more, sometimes a little less, without the pains
having ever been excessive and accompanied by fever; but the patient
has often been obliged to enter the hospitals, leaving them, after a
month or two, ameliorated but not cured, He has walked with more
and more dilficulty, and finally was no longer able to do it without
the aid of crutches, and even then with much difficulty and fatigue.
"We find the following condition of aftitirs.

II. In the left knee, a very evident effusion, without enlargement
of the patella, without hyperostosis of the femur, without appreciable
thickening of the synovial membrane, without movable or immovable
foreign body; no lateral mobility ; voluntary movements but slightly

I limited, notwithstanding the pains; communicated movements of
flexion and extension almost as free as in the normal condition ; per-
ception by the hand and ear of very marked cracklings during both
voluntary and communicated movements; finally we find that de-
formity which is known by the name knock-knee, and which consists
in the deviation of the leg outwards, and in the very marked promi-
□ence of the inner condyle of the femur.
What is the anatomical explanation of these symptoms, what will
be the ultimate course of the disease, and what name should we give

DBY ABTHRITIS OP THB KNEE, 315'

I explain the effusion, as I did in aimpie hydrarthrosis, by a congeft-
tioi) of the synovial membrane with exaggeration of its secretory func-
tion, and diminution of ils power of absorption. But I suppose, for au-
topsies have phown it in several eases of this kind, thnt the conge
ia not general, and that it occupies more particularly the folds ki
as the synovial fringes.

I attribute the sensation and sound of crackling to a lesion which
has often been found in the autopsies, that ia, the loss of polish and
the'partial destruction of the diarihrodial cartilages. I do not know
exactly to what degree this destruction has advanced, but recalling
the lesions described by Redfern and M. Eroca, lesions which I havw
already had occasion to mention when speaking of the other varieties
of arthritis, T believe that the arrangement in parallel fibres which
constitutes the velvety condition, and its coincidence with a partial
disappearance of the cartilage, cause the crepitation which now occu-
pies us, I know that pathological anatomy leaves a gap here, for I
have never had, and no one, so far as I know, has ever had the
opportunity to dissect subjects in whom this symptom had predomi-
nated, and to see exactly what lesion had produced it. Moreover you
might raise the objection that I have already spoken of — possible
velvety change in patients who had ofi'ered no crepitation. That un-
doubtedly was due to this, that the movements, limited by the pain,
by the rigidity of the synovial membrane, by commencing adhesions,
and above all by muscular contracture, were not sufBciently extended
to cause this loud friction; for I now call your attention to the fact,
as I shall undoubtedly do again, that one of the characters by whica
this patient's arthritis differs from those of which I have heretoforfit,
spoken, is that the muscles are not conlractured and immovable, erf'
are so to a much less degree.

As to the defurmily, we must not consider it congenita!, as thef
knoi:k knee often is. For the patient tells ns that his knee waa
always well shaped, and that the deformity appeared only five or sir
years ago and has increased little by little. It is then accidental, aui
I cannot explain it otherwise than by a rather vaguely described
lesion of which I, for my part, have not thus far been able to give an
anatomical demonstration, I refer to the sinking of the outer con-
dyle caused by absorption of its substance, absorption undoubtedly
prepared by rarefaction. I have already often spoken to you of rara-
faction of the cancellous tissue; I told you that it sometimes accompa-
nied one of the varieties of osteitis, but that it might also occur with-
out osteitis, that then it coincided with an infiltration of fat, and thai.
it was a result of age. I spoke to you of fractures made possible by*-
this rarefaction, but I have not yet had occasion to show you the
concomitant disappearance of a large part of the rarefied cancellous
tissue. It is precisely that which seems to me to have taken place
in this patient. Tlie same ttiiag probably occurs in other patients
. affected with this or some other accidental deformity, hence the name
(deforming arthritis used by some authors.

What will be the ultimate course and termination of this disease?!
Observe well two principal things: Ist. The arthritJa, although it hi

I
I

DISEASES OF THE ABTI0ULA1ION3.

lasted a long lime, has not suppurated; 2d, It has not caused an-
ehylosia, even incomplete. Now by the phenomena which we have
found, by what has taken place in the right knee, of which I shall
presently speak, by the age of the patient, by what the clinic and
pathological anatomy have taught ua about this subject, I am con-
vinced that the (Jiseasa will go on in the same way. The arthritis
will persist, without terminating either by suppuration or by anchy-
losis. W hy so ? Because there is, in the phlegmasia of this articula-
tion, a nature, a mode, as they still say, a tendency, aa I have also
said, which does not lead to these results. The articulation will not
suppurate, because it is not fungoid, and because the patient's constitu-
tion is not aurofulous; it will not anchyloae, because there is neither
the rigidity by thickening, nor the false membranes which ebaracter-
iae plastic arthritis, and perhaps also because, as the muscles continue
to act a little, the movements, slight as they may be, will prevent
the rigidity and adhesions from establishing themselves to the degree
necessary to produce anchylosis. I can carry the explanation no
further. It is evident that here we touch upon the question of the
intimate nature of the disease, and, as in all questions of this kind, we
are stopped by the unknown.'

And now what name shall we give this aifection? After what I
have just said, it will be neither that of congestive arthritis, nor
that of plastic arthritis, nor that of fungoid arthritis. It might, strict-
ly speaking, be that of dropsical arthritis, for there is liquid in the
articulation. But no, I shall not employ this expression either, for
it would give you false ideas upon the prognosis and treatment. In
fact, to these words, dropsical arthritis and hydrarthrosis, is attached .
the idea of curable anatomical lesions, of temporary physiological
troubles, of probable cure, in a word, and of efforts to be made by
the surgeon to obtain this cure. But here you have a congestion
which has become permanent, and perhaps subsequent inappreciable
transform.itions into cartilaginous tissue about the synovial fringes;
you have irremediable lesions of the diarthrodial cartilages and the
epiphysis. None of that will disappear. The tendency is not to get
well, but rather to get worse by the development of other disorders
of which the present lesions are only the prelude, and of which the
right knee will show us examples.
' There is only one word, in the present state of surgery, to express
both the lesions and the very curious nature of this disease — it is that
of dry or deforming arthritis. Undoubtedly it will seem strange to
you tnat I call dry arthritis a disease which has an effusion for one
of its manifestations. But I have to use a word which will make you
feel that it is not an ordinary hydrarthrosis, and I have no other

' An apparent aontrsdictian maj be fnnnd between the cltaraotera nhiob I giro
to dry BrtliritU of the kn«e, mid tlKi.-te nliiuh' I gave, page S4, to tlie arlhritia oFihe
lai'salgia of aiiolBacenta. Bat thum ( made only a porapanBoii ; I did not wiali lo
estiiblitih. a. oouplele identity. IF tlis t^irittil tLrtbritia of adalaacenta resHml>le9 dty
artbritifl b; tb« le^^ion of Ihe cartiUges, it diSiir.i rroro it by its aucouipanying reuutlon
apnn tile mu9iil<is, by possibility of uuubyloiiia, aud b; its ourabiiity after probnbla
repair uf tlie alusmted cartilages.

DRY ABTHHITIS OF THE KNEE,

than those I have jwst tiBetl. But I shall say more upon this point j
after having ppoken of the right knee.

III. The phyairal symptom of tlie right knee wliich first strike^
us, is a considernble increiiae in size, affecting especially the lower exJ
tremity of the femur which at the same time is rounded. Placing^
your band upon this swelling yon find it very hard, and, us it were, '
lobnlated, all the hard points have the consistency of bone and are
evidently united with the femur. There are similar, but much fewer,
roughnesses upon the tibia. The patient can make a few movements ^^J
of flexion ; but it is not a muscular resistance which limits them, for^.^^^^
taking the limb in both hands, you can give it these movements very^^H
easily; at the same time you feel and hear a loud crackling; very^^^J
extended abnormal lateral movements can also be made; and, finally, ^^^
by analyzing carefully the situation of the tibial epiphysis, we see that
it is placed too far behind, that it cannot be brought forward, in a

»word, that it ia in that state of displacement which is often called sub- ^^^
luxation. ^^H

I ask for this knee the same three questions as for the other, ^^H

And first, what ia the anatomical explanation of the different symp*^^H
ioms ? Of course the idea may at first occur that the swelling of thei^^H
femur i.i due to an osteo-sarcoma. But if it had been that diseaser^^H
during the time it has lasted it would have extended to the shaft, oP^^H
the femur and would have softened. Is not then this hardness that ^^
of a hyperostosis ? I have avoideii using this word ; for hyperostosis, "

as we understand it, occupies the shaft and the whole thickness of
the compact portion of the long bones, while here the bony swelling
corresponds to the cancellous extremity, and seems to occupy the ex-^^^H
ternai layers rather than the parenchyma of the epiphysis. Now, weir^^f
have here, gentlemen, a special lesion with which the labors of moderU'^^H
pathological anatomy have made us acquainted, that is, osslfleations-.^^H
of the edge of the cartilage and the neighbouring periosteum, perhaps. ^^H
even of that portion of the synovial membrane which covers the latter., ^^^
These ossifications are analogous to those which, in the same variety ^^H
of arthritis, we sometimes End upon the inner face of the synovial
membrane in the place of the fringes, and to those which sometimes
become loose in the articulation and form a variety of movable for-
eign bodies. In a word, these are rounded concretions or stalactites, ■
osteophytes, as they are still called, of complex origin, due to an ab^d
normal ossifying power of the articular cartilages and of the synoviai'l
membrane. What makes them very remarkable and uncommon inM
this patient is that they are much more abundant and agglomcraledl
than they generally are in cases of this kind, ,r

Figure 21, for example, which I borrow from M. Duplay, repre--'
aents osteophytes much less agglomerated than those of our patient.

As for the crackling, I explain that also by a lesion of the carti-
lages ; I think even that it is no longer a question here either of the, 1
velvety condition, or of the wearing away indicated by Prof. Cruveil- J
hier in 1824,' I think there is a more advanced lesion, an extensive 1
destruction of these same cartilages, and friction of the bony articular I

^^^^^v ■ Cravuilhler, Aralitves de Uudecine, 1824, Ire surie, tome ii.

DIdKA3K3 OF THE A BTICULATIONS.

surRicea which have become hard aiiJ ehiirnatetl This eburnation
is perhaps explained, aa M. Ruiivier admits, by calciBcation of some
of the cartilaginous cells, and more probably by a hypertrophy lim-
ited to the compact sub-cartilaRinous layer, which, instead of dis-
appearing, as in fungoid arthritis, has undergone a process of con-
densation, in which, however, neither the parenchyma of the cancellous
nor that of the compact tissue has participated ; this would be the
continuation of the process of ossification which tidces place at the
perijihery, without, although for
absiilutely unknown reasous, the
participation of the interstilial
portions of the bone. In any
case, you recognize here a pecu-
liar lesion which haa been de-
scribed by Crnveilhier' under
the name of eburnation or ebu^
exo.-tusis of the articular sur-
fuces.

But should we not also attri-
bute the crackling to lesions of
thesynovial membrane? I told
you that there was no effusion.
Might there not then be a con-
dition of dryness which, during
movement, would give crepita-
tion ? I admit that, studying
the origin of this word dry ar-
thritis, I have examined speui-
mens which have been shown
me, to see how fur the synovial
membrane participated in the
osieophytfu. i. Condyle, of iha femur. B. ir- dryncHS iudicatcd; but I have
puwub."'''^"'^ "' '""*' '^' "' ^' ""^''P''''^"- "■ never found it dry enough to
account for the crackling. In-
deed there was always enough humidity on its inner surface to make
the expression seem to me unjustified.

Are there no other lesions of the synovial membrane in such
cases? I do not speak of the congestion which probably occurred
at the beginning, and which undoubtedly haa now disappeared. I
allude only to the fibrocartilaginous and even bony transform aiiona
which have been pointed out as possible in the synovial fringes. If
such transformations have taken place we can understand that they
might contribute to the production of crackling. But there ia no
sign which authorlaes me to affirm the existence of this lesion.

Lateral mobility is too marked in this patient for me to think of
seeking its explanation, or at least its sole explanation, in the destruc-
tion of the semilunar fibro-oartiiages. I do not doubt the softening
and perhaps destruction of the lateral and even of the crucial liga-
ments. But has it been a simple absorption, or a fatty degeneration ?

', EiillBtliis lis ia. Soci^tea

i. p. 195.

DBT ARTHRITtS OF THE KNEE. 319

This point haa not been ihorouglily atiidieil. T only know that M.
Duplay' makes fatty transformation of the ligamenta ao almost con-
stant lesion in diseasea of this kind.

As for the sublnsation, it ia also explained by the weakeniiig of
the meana of union, and especially of the posterior ligament whiuh
would have been affected by lesions the same as those of the lateral
and orucial ligaments.

In short, gentlemen, we have the explanation of the symptoma in
a aeriea of lesions affecting all parts of the joint, and consisting in:
congestion of the synovial membrane, destruction of the ligaments,
new ossification by means of certain points of the synovial menibraDe,
of the articular aurfacea, and of the periosteum, without false mem-
branes leading to anchylosis, without any tendency to suppuratioo,
without condensing osteitis of the adjoining diiiphysea.

"What name then shall we give the disease? As before, I am not
authorized to use any of the denominntiona which I employed in the
precedent lecturea, I need one which indicates iheae three principal
characteristics: no anchylosis, no suppuration, long duration and
incurability (for there is still less reason to hope for a cure in this
liilter knee than in the other, because there is a too profound modifica-
tion of the normal anatomical condition). I still have only the name
dry arthritis to express all this. This name has the advantage of in-
dicating a real characteristic, the persistence of an inflammatory con-
dition which from time to time becomes subacute. It haa certainly
the diswdvantnge of exaggerating a symptom, the dryneas of the
Synovial membrane, and of not sufficiently indicating the tliree
cliaracteriatic tendencies I mentioned. I use it, however, because I
have no other, and because I should not easily find one which would
belter express all the negative and positive characteristics of this
variety of arthritis.

IV. Observation of the two knees of this patient has already shown
ua that dry arlhriti,^ presents different degrees or characters. Kecall
the patients I have shown you at diffiirent times in the lectures of
thia and the preceding years, and you will see that there are still
other varieties.

We often see at our consultation, and sometimes in our wards,
patients verging on old age, whose only symptoms are articular pain
and cracklings. I have often pointed out arthrites of this kind after
fractures of the thigh, contuaiuns and sprains of the knee, after sub-
acute rheumatisms, and almost always in patients who are more than
fil^y years old,

I showed, in 186a and 18fi9, ward Ste. Catherine, No. 19, a womaa
46 years old, whose left knee, following an attack of rheumatism with
hydrarthrosis, had been painful for several years and the aeat of an
infirmity, the principal cause of which was an excessive mobility
which seemed to indicate a destruction of all the means of union.
Tou remember that the lateral mobility was vsry great, and that I
was even able with my hands to move the tibia outwards, inwards,
forwards and backwards, so as to produce a subluxation in these

i Folllu at Duplnj, TrMte de Patbologie, tume ii. ^^^^^h

320 DISEASES OF THE ABTICULATIONS.

different directions, Yi»n remember that all these movements caused
a dry sound which was heard by those standing about the bed, and
which must have been caused by the contact of very hard Burfauea,
probably the eburoated articular ones. At that time the hydrarthrosia
waa slight. It should be nuted also that I had made, a few montha
before, an injection of the tincture of iodine, which, strange to say,
had not caused acute arthritis, or, consequently, the anchylosis I
Bought, as if the articulation had lost, at the same time with its princi-
pal anatomical dispositions, its aptitude to inflame under the influence
of a severe irritation. The name dry or deforming arthritis waa then
the only one that I could give to this disease.

Hence I concluded thai, clinically, we have to distinguish at least
four varieties of dry arthritis: a first and very common one, in which
the crepitation and the moderate but habitual pains are the dominant
phenomena, and in which, doubtless, the lesions affect only the syno-
via] membrane, which ia congested, and the diarthrodial cartilages,
which are'eroded and scratched; a second, in which a temporary or
permanent synovial effusion ia added to the preceding leaiona and
symptoms; a third, in which there is lateral mobility and more or less
subluxation indicating the destruction of the lateral ligaments; and
a fourth, in which, with or without destruction of the lateral liga-
ments, we find osteophytes, either in the synovial membrane, or about
the diarthrodial cartilages; furthermore, different degrees of deformity
by partial osteo-malacia of the articular extremities may be found in
all these cases.

Etiology. — I have carefully questioned the old man, the present
patient, and have found no cause to which I could refer the affection
of his Ifnees. But as both articulations were attacked at the same
time, and as we are always disposed to explain multiple arthritis by
a rheumatic diathesis, I am willing to admit, although the patient has
had no other rheumatic manifestation, that the disease is due to this
general cause, I should, however, tell you that you must expect to
see dry arthritis appear in subjects who are not rheumatic. In those
cases where it is absolutely single a certain complaisance is needed to
admit the rheumatic diathesis. Also when it follows a traumatic
lesion, a wound, a contusion, a S|irain, a fracture, this same cause
cannot be invoked. That is why I am still obliged to appeal to an
unknown cause in tho.se cases ia which rheumatism cannot be legi-
timately admitted. Is it not also necessary, even in those cases where
the latter is admissible, to suppose a particular form of the diathesis
which gives rise to these man i testations so special and so different
from those by which rheumatism generally betrays itself?

On account of what precedes, I regret that our learned colleague,
M. Charcot, has given the anatomical description of dry arthritis under
the title of chronic rheumatism^ On the one band, the arthritis ia
question is not always rheumatic; and, on the other hand, rheumatism,
as I have told you, gives rise to other forms of curable chronic ar-
thritis (plastic and dropsical). There is then a disadvantage in giving

■ Cbarcot, Le^ona bqt lea MaladisB dss TluillnrcU at les Mal&dias alicaai^Mi,,

^" OET ARTHRITIS OF THB £NBE. 321 ^^M

a description of chronic rlieumatiBm, which leaves the impression that ^^H
this disease lea(1s inevitably to the incurability of dry arthritis. ^^|

If you wish to conBne yourselves to the information fiirui.shed by
the clinic, do not forget, gentlemen, that dry arthritis of the knee, of
which thus far the anatomical characteristics have been studied (ar
more than the symptomatology and the etiology, presents, with refer-
ence to its origin, two forma: it is primitive or consecutive. When
it is primitive, it may be rheumatic, as I told you, or of another
nature which remains unknown to ua. But most frequently it is
consecutive to one of the forms, with which you are acquainted, of
acute, subacute, or chronic arthritis. You see it, I repeat, after I
neighbouring contusions, sprains, fractures, which have given rise to I
one of the arlhriteB which I have just mentioned. You see it also I
after pure rheumatic arthritis, which at first takes on the chiiraelers j
of plastic arthritis, and then terminates by the lesions of dry ar- (
thritis instead of by resolution or anchylosis. Finally, you see it j
after arthritis, which has been at first purely dropsical. You may J
also see it, as M. Charcot's work testifies, after gouty arthritis, that in |
which the initial lesion is the invasion of the cartilaginous cells, and j
the other constituent parts of the articulation, by an excess of uric j
acid and urate of soda contained in the biood.^

You will more rarely see fungoid arthritis followed by dry arthritis, |
because, as you know, it tends rather to terminate by suppuratioti
and sometimes by anciiyloais, and also because it belongs to the youth- '
ful period of life, and because there is one almost necessary condition '
for the development of dry arthritis, that is, senility.

Indeed, gentlemen, and it is with this final consideration thiit I (
shall terminate the etiology, the tendency of arthritis to end neither i
by resolution, nor by anchylosis, nor by suppuration, and to be acoom- '
panied in certain cases by ligamentous destructions and osteophytes,
is rarely seen before the age of fifty years, and developed especially in
old age. But it happens in this, as in the rarefaction of the cancel-
lous tissue, that certain subjects have this pathological aptitude a little
earlier, say from' forty to fifty years of age, and in consequence of a
premature local senility.

D-eulmeui. — I have nothing useful to say about the treatment. We
have only to treat the new inflammatory attack by rest and poultices.
As soon as it ends we shall advise compression of the dropsical knee
with a flannel band, and h roller bandage, including a posterior splint
for the right knee, which is so movable, and we shall let the patient
resume tlie use of his crutches, without which he cannot now get along.
If he asks, on account of his infirmity, which is only too real, admis-
sion to Bicetre,' I shall obtain it for him.

■ While Doriually only traces of urio aeld exist in Clia blood, frnia B to IT ceuti-
grannnea are t'aiiuit iti lUUO nirauiiDes of blood during mi attaul: of Ilia gout.
* Hospital for iudiguut, iuflrm, aud Incurable old men, altuatudjual outside Paris. '

322 DISEASKS OF THK ARTICULATIONS.

LECTURE XXXIX.

GENERAL CONSIDERATIONS UPON ARTHRITIS IN THE OTHER

ARTICULATIONS.

Arthritis is traumatio or Bpontaneous. I. Traumatic arthritis is with or without «
wound — Arthritis without wound is congestive or plastic, and ordinarily gets
well by resolution — The elbow an exception in children — It goes on to chronic
arthritis and to dry arthritis in old people — Examination of the question with
reference to the upper limb and to the lower limb. II. Spontaneous arthritis
is multiple, or mono-articular — Examination of the varieties : 1st for the large
articulations of the lower and of the upper limbs ; 2d for the small articuIatioDS
— Assimilation of nodosity of the joints to dry arthritis — Difference of origin
between gouty arthritis and rheumatic arthritis ; analogy of the ulterior lesions.

Gentlemen: It would be interesting and useful to do for each
one of the other articulations what I have done for the knee, that is
to say, to point out to you the different clinical forms under which
arthritis may appear in them ; but I should not have a sufficient
number of examples to show you, because these arthrites are not so
frequent as those of the knee, and because certain varieties are
treated rather in the medical than in the surgical service; and farther*
more it would involve much repetition.

It will suffice to offer you a few generalities upon the subject; and
these generalities will be simple and short, for we shall have to deal
with the same questions of etiology, pathological anatomy, and prog-
nosis, as in the knee.

In all the articulations the arthritis is either traumatic or spon-
taneous.

I. Traumatic arthritis, — In all of them traumatic arthritis is
threatened with suppuration when its origin is a penetrating wound;
but the smaller the articulation, the less intense and the less danger-
ous are the general effects of this suppuration when it takes place.
As for traumatic arthritis without wound (that is to say, after fracture,
dislocation, contusion, sprain), the form which you see it take most
often is, at the beginning, the subacute form, congestive and plastic,
with or without effusion of blood or of synovia, and afterwards the
chronic form tending to terminate by resolution and return of the
normal functions, sometimes by complete or incomplete anchylosis,
sometimes by dry arthritis. The differences depend upon the articu-
lation or upon the age of the subject. One word upon these differ-
ences.

A. Articulations of the upper limb. — Traumatic arthritis (without
wound) ordinarily gets well by resolution in children, adolescents,
and adults; termination by complete anchylosis is the exception.
But after the age of fifty years, and consequently in old people, ter-

GENERAL CONSIDERATIONS DPON ARTHRITIS.

ruination by rigid incomplete anchyloeis and by flrv nrthritis is qnite ]
frequent, I have often shown yoii that, after dialoeationa of the j
bhoulder, movemenls are re estiibirshed very well in young patiente,*!
put that they long remain slow, dii^colt, and painful in subjects whirl
B advanced in age.
As for the elbow, there ia this that is peculiar to it and very '
Itrange: children, up to the age of adolescence, are much exposed to
»nchylo.'<is after traumatic, artdritis, even after causes that are appa-
rently slight. You should know ihis in order not to condemn ohildren
a a too prolonged rest. By exercising the joint early you can pre-J
fenl the establishment of adhesions, or break up those which havt
ftlready begun.

In the wrist traumatic arthritis has less tendency to anchylosis,
nnd much to end by complete resolution; butafter the age of fifty yea ra
anchylosis by rigidity alone or by adhesions, prolonged arthritis, and
incurable dry arthritis are quite frequently seen. 1 have often ex-^
plained this subject when speaking of fractures of the lower extremilm
of the radius.

In the digital articulations we must distinguish between direc
traumatic arthritis, that is to pay, that which is consecutive to lesiontC^
of the articulation itself which becomes affected, and indirect traur
matio arthritis, or that which invades the digital articuhuions in eon* .
Requence of the treatment by immobility of a traumatic lesion situated '
above, in the forearm, elbow, arm, or shoulder. I have told you that
in such cases I admitted arthritis by immobility. Although I have had
no occasion to make an autopsy, I presume, from facts observed upon
the living patient, that these digital arthriles are congestive audi
slightly plastic. In genera! they get well by resolution after s
weeks or months of care; but we should have to fear, especially in J
old people, incomplete anchylosis by rigidity, and even complete a
chvlosis, if we did not have the affected jnints moved frequently.

B. Arlrc'ilafions of ike lower limb. — There is traumatic arthritiajj
without wound, of the hip as of the shoulder. It is congestive andl
filighlly plastic, and tends always to terminate by complete resolu-|
tion in young subjects, by prolonged chronic arthritis and incurable J
dry arthritis in old people.

The same i.a true of the tibio-larsal articulation and those of theB
foot. It is by the age alone that we can foresee whether the arthritia.B
will get entirely well, or whether it will pass to the incurable t.
dition of dry arthritis.

In shori, in subjects who are still young, traumatic arthritis,
although it be congestive and plastic, is nireiy suffieiently so to cause
anchylosis, and the treatment by movements communicated every
day has the advantage of opposing this tendency successfully, and
almost always without bringing back the inflammatory conditional
which I mentioned when speaking of spontaneous arthritis of the J
knee, and which trouble ua so oAeo in spontaneous arthritis of the J
other articulations.

II. SjiontaHeous arlhrilis. — There is a very common variety,
acute or subacute polyarticular arthritia, yrhicb you know uoder thf

824 DISEASES OF THE ARTICULATIONS.

name of articular rheumatism, and which you see more often in
the medical wards than in ours. It offers these remarkable peculiari-
ties, that it is ordinarily limited to a little effusion in every articu.
lation affected by the congestive form, and complete resolution is the
rule. I shall then have to make special reference to the acute and
subacute monoarticular arthritis and to some forms of multiple
chronic arthritis. Here I need no longer take the articulations one
by one; it will be sufficient to describe the large and the small ones
of the upper and the lower limbs.

1st. In the upper limb the large articulations rarely become the
seat of single acute arthritis, either gonorrhoeal, or simply rheumatic.
We have, however, met them in those of the shoulder and of the wrist.
As for the shoulder, I have been struck with the facility with which,
in spite of all our care, this arthritis ends in complete anchylosis.
The indication is to oppose this tendency by means similar to those
I mentioned for the knee. But it will often happen, as I reminded
you a moment ago, that you will not be able to continue the use of
communicated movements, on account of the return of acute inflam-
mation.

Among the chronic arthrites there is one variety which you will
rarely find in the large articulations of the upper limb, it is hydrar-
throsis. You see, on the other hand, fungoid arthritis quite often at
the elbow and at the wrist. At the elbow, termination by suppuration
is frequent and comes quite rapidly. This fungoid arthritis termi-
nates more often by anchylosis, without preliminary suppuration, in
the wrist than in the elbow, and for both these articulations, as for
the knee, the indication is always to strive, by all the local and
general means at our disposal, to substitute anchy losing, plastic ar-
thritis for fungoid arthritis, which tends to suppuration. It is always
the best termination that we can hope for; the means which enable
us to obtain it would moreover give a cure by resolution, if the patient
was in the very exceptional category of those in whom, after a com-
mencement of fungoid transformation, the synovial membrane can
resume its normal, anatomical, and physiological condition.

Primitive and consecutive dry arthritis is sometimes seen in the
large articulations of the upper limb, but it is less common there than
in those of the lower limb ; it prevents the same anatomical varie-
ties.

2d. Among the large articulations of the lower limb the coxo-
femoral is rarely affected with acute and subacute plastic arthritis, or
if it is affected, the symptoms, on account of the depth of the joint,
are so difficult to distinguish from those of the fungoid synovitis called
coxalgia that they are easily confounded. Jbor me, when I see after
several months anchylosis succeed a disease which has been con-
sidered coxalgia, I am disposed to believe that it has been, not a fun-
goid synovitis tending to suppuration, but a plastic synovitis.

The tibio-tarsal articulation is, after the knee, that which is the
most often affected with solitary acute arthritis, and especially with
that which has a gonorrhoeal origin. The termination there by an-

JOKNERiL C0N3IUERATI0N3 UPON ARTHRITIS. 325

ctylosis is quite common, and takes piiice by the mechanism wliicb I
^escribed for the knee.
If the articulation of the hip is not frequently aftected with acute
arthritis, it is in return much exposed to chronic arthritis, especially
to the fungoid form in young subjects, and to the dry form in old
people. You know that the first description of the arthritis which
we call dry, was given for ihe hip, at the beginning of this century,
under the name nl' morbus coxte senilin.

The tibio-taraal articulation is leas often affected with white swell-
ing and dry arthritis than the knee and the hip, still we see them
there quite frequently.

To recapitulate, gentlemen: among the large articulations that of
^- the knee, first because it ia the largest and then because it belongs
^L.to the lower limb, is the most exposed to all the varieties of single
^B dcute, subacute, and chronic arthritis. It is for this reason that I took
^f my principal types from it. But the etiological, anatomo-pathologieal,
~ and clinical details into which I entered apply to all the large articu-
lations. By placing in relief these four principal forms — plastic,
dropsical, fungoid, and dry — the natural tendencies of each one, and

I the consequent therapeutical indications, I wished to give yon the
means of directing your conduct at the bedside of the p;itient when-
ever you should be called upon to treat an arthritis. But I want to
tell you, in closing, that in the large articulations these forms are
sometimes mingled and cause difficulties in diagnosis and prognosis
rather than in treatment. It will happen to you especially to hesitate
long before deciding if a chronic arthritis is simple and still curable,
or if it has passed to the condition of incur.ible dry arthritis, and
especially to the variety in which there are as yet no appreciable
osteophytes and eburnation. Remember that it is the age above alt
which ought to enlighten you, and that in any case there is no dis-

t advantage in admitting at first that which is most favourable to the
patient, that is to say, curable arthritis, and to make your prescriptions
correspond.
3d. As for the small articulations, you will rarely see single acute
and subacute spontaneous arthritis in the upper limb, that is to a ay, in
those of the hand and fingers, Tou will more oiien see multiple
chronic arthritis, that is to say, the simultaneous invasion of several
phalangeal articulations, and sometimes of all, by an essentially
chronic disease, of probably rheumatic nature, which you hear called
rheumaiic arlhrick,' and, for the articulations of the last two phalanges,
HeberderCs nodosities. I do not know why they have given these
apeeial names to these digital arlh rites. Perhaps it was because their
ideas were not sulficieutly well established as to the varieties of ar-
thritis in the rest of the economy to establish a relationship between
I those of the fingers and those of the other regions. Tliis relationship
I seems to me to-day very possible. The clinic has taught ua that
L rheumatic arthritis does not suppurate, and that sometimes it anchy-
I loses by fusion, sometimes it persists indefinitely without anchylosin^~

' Eliaamatiam iioaeux. Bheumatto arlLrltis, coiloait/ of tlis jotate.

826 DISEASES OP THE ARTICULATIONS.

In the first case, it is a plastic rheumatic arthritis, in the second a dry
arthritis. I admit that a rigorous diagnosis, so long as the anchylosis
is not established, is a little difficult, as is also the ease in the large
articulations, but I repeat that that has not a great importance prac-
tically. Always try to cure your patient. If after a year or two of
treatment you have not succeeded and anchylosis has formed, your
diagnosis is made. If anchylosis has not formed, and your patient is
old (it is almost always old persons who have rheumatic arthritis),
be sure that you have to deal with incurable dry arthritis, with more
or less deformity, produced either by bony deposits or by muscular
retractions, deformity of which M. Charcot's book offers you very
fine plates.

As to Heberden's nodosities, I think they have honoured this physi-
cian too much in giving his name to a disease which he has the merit
of havins: distinguished from gout, but which he described without
sufficiently knowing the French works of Cruveilhier, Deville, and
Broca on dry arthritis. For the little lumps which he found in the
dorsal face of the second phalanx, near its articulation with the third,
are nothing else than the osteophytes of dry arthritis; they coincide,
as M. Charcot has well seen, with some of the other lesions of this
disease, especially with eburnation and other osteophytes. It is then
simply a dry arthritis in a small articulation

The small articulations of the lower limbs are also affected with
the chronic forms of this rheumatic arthritis of old people. You
will also sometimes find there acute gouty arthritis, especially at the
metatarso-phalangeal articulation of the great toe, and gouty chronic
arthritis. I share fully the opinion of Garrod, and that which Charcot
has so well formulated, upon the essential difference which exists be-
tween gouty arthritis and rheumatic arthritis. I admit very willingly
with them that the initial lesion of gouty arthritis is the invasion of
the diarthrodial cartilages and the other constituent parts of the ar-
ticulation by uric acid and the urate of soda. But this initial lesion
once established, the anatomical characters of ordinary arthritis are
added, simple synovial congestion, with or without effusion, in the
acute and subacute varieties; thickening and false membranes in the
slower varieties, tendency to complete anchylosis when the patient is
old, prolongation under the form of congestive and still curable
chronic plastic arthritis, and finally the dry form, with coincidence of
the tophic deposits peculiar to gout and the special lesions of dry
arthritis. In a word, notwithstanding their special etiology and their
peculiar anatomical beginning, gouty articular affections are arthrites,
the lesions and ultimate course of which are analogous to those of
other articular inflammations, and especially to those caused by rheu-
matism. That is the reason why they were authorized to consider
gout and rheumatism as the same disease, at the time when they did
not know the real cause and mode of formation of the gouty arthritis.

PART VI.

PHLEGMONS, ABSCESS, FISTULA.

LECTURE XL.

. Autopsy of R Buliject n-liose death waa oaosed by n cniituseil wonnd of the little^
finger followed lij indButmHtian of t1i« ayuovini bursa of Iha llt<xani~-Patrll
iufcalloii— Freseiioe of pus in the EynoTial aheatli of the flaxor leoriuiiB of the
lUtlti fiogar— Spread of the iiiflAinmfitiDn hehiud the bandle of teiidons in the
palm of tliB hand — Us extension lo the syuoilal shaRth of Iha thumb — Integ-
rity of the aynoTial sheaths of tlia other fingers. II. Tendioona synovitis of the
flexors, partly suppurative — luflamraation alartiug from the litllo fliiger — Ah-
anessufi of Ilia theuar aud hypotheuar emiuenoeB, without concomltaut palmar
abscass— Explanailnn by a conihinatjon of plastia synovitis with supparatlve
synovitis — Deap diffuse phlegmon of tlie forearm ; its termination h; reioln-

tloD.

Gentlemen : T. I place before you an nnatomieal specimen coining
from a man 55 years old who occupied bed No. JSS, ward Saiute-
' YJerge, for about twelve days (from the 23d of Deoemberj 18t>8, to the
Bthof Januiiry, 1889).

You remember that this man had had the end of the little finger
'of his left hand crushed by a stone, which had caused a contused
ind, occupying the palmar face of this finger between the middle
'of the ungual and the middle of the second phalanges, and accompanied
by fracture of the first of these bones aud denudation of the extremity
'of the flexor tendons.

A suppurative inflammation bad been developed and had gained
the deep parts of the hand and forearm. Three weeks had already
passed since the accident when the man was brought to the hospital.
The most prominent symptom then was a most serious general malaise,
characterized by frequency of the pulse, prostration, dryness of the
tongue, yellowish Eubicteric tint of the sliin, profound alteration of
the countenance, and finally a tranquil and almost continual delirium.
According to the information which we have obtained, the patient
vas not given to drink.

Aa local symptoms we found a very marked swelling and redness
"of ihe forearm and hand. The thumb and the little finger werf"
much more swollen than the other fingers. All the^e parts presenbg

828 PHLEGMONS, ABSCESS, FISTULA.

doughiness and deep oedema. We did not find superficial fluctuation,
but by pressing steadily with one hand upon the palmar surface of
the wrist, and slowly pushing back the soft parts of the forearm an
inch or two above with the other, I felt that the lingers of the Grst
were pressed up. You noticed the position which I gave the limb
in order to avoid all chances of error when I made this examination;
I raised the hand and rested its dorsal face together with the whole
length of the forearm upon a pillow. I thus gave the linrib a support
which prevented it from being pushed back by my exploratory manoeu-
vres, and after having demonstrated several times the existence of deep
fluctuation by sending this wave alternately up and down the arm,
I was sure that we had to deal with one of those deep and difluse ab-
scesses of the forearm which are due to the propagation towards this
region of inflammation starting from one of the fingers, and much
more frequently from the thumb and little finger than the others.

Notwithstanding the intensity of the general symptoms and the
gravity of the prognosis, I at once made a deep incision in the fore-
arm. I divided layer by layer along its centre, for a distance of
about three inches, the skin, the subcutaneous cellular tissue, and the
deep fascia. I then tore with my finger, so as to avoid hemorrhage,
the cellular tissue of the first inter-muscular space which I found, and
thus reached a deep collection of pus limited behind by the pronator
quadratus and the interosseous space. A considerable quantity of
good phlegmonous pus escaped. A few days later a second abscess
was opened on the inner side of the little finger.

The escape of pus from the forearm remained difficult, notwithstand-
ing the bunches of lint and the drainage tubes which I employed
successively. The febrile condition continued, and the 29th of
December the first chill took place; others followed, the patient grew
weaker and weaker, and died.

I expected to find metastatic abscesses, as they sometimes form
after these deep abscesses, the pus of which escapes with difficulty on
account of the obstacle offered by the muscles which overlie them.
But there were none, and I. had to suppose that the patient had suc-
cumbed to one of those putrid infections, bastard septicaemia, which
are due at the same time to severe traumatic fever and pysemia.

But it is not upon this point that I wish to speak to-day. What
I want you to notice particularly is the seat and the extent of the
suppuration.

Look first at the little finger, the starting point of the afffection.
We have opened the sheath of its palmar tendons ; you find pus in it
covering on the one side the parietal layer of the synovial mem-
brane, and on the other the tendons which are also softened and dis-
associated. Follow the collection towards the hand, and you see that
it passes behind the bundle of the flexor tendons, and continues with-
out interruption or line of demarcation as far as the middle of the
forearm. Let us now look for the lower limits of the collection in
the palm of the hand. It stops above the metacarpo-phalangeal ar-
ticulations, and does not extend into the tendinous sheaths of the
index, middle, and ring fingers, but on the outer side the pus continues

ABdCESSES OF THE HAND,

in the sbeath of the ttiumb, even to its very end. This aiiatoinicatj
disposition of the purulent collection recjiUa to those of you who have
HuHioiently studied anatomy that of ths synovial buraa of the flexors
in the palm of the hand. You know that in some subjects this bursa
is double: there is an inner one whieh corresponds to the palni of the
hand and the little finger, and an outer one which is destined solely
for the long flexor of the thumb. But in most people the cavity'
single and is composed: 1st, of a central portion which stops at tha!
lower part of the palm of the hand, and consequently does not extend'!
to tbeextremity of the three middle fingers, in which the flexor tendons'
have separate sheaths ; 2d, of two lateral prolongations which aceom.
pany the flesor tendons of the little finger and thumb to thei
t rem i ties.

You see, then, that here the suppurative inflammation starting from
the little finger must have been propagated along the inner
of its sheath to the common portion of the great synovial bursa, anti,
thence to the prolongation of the thumb. At its upper extremity-
the great synovial bursa is largely open and communicates with thSi
deep cellular tissue of the forearm, to which the infiamniation has;
been transmitted either by a propagation of the phlegmasia itself or
by an effusion of pus coming from the synovial bursa after ulceration;.'
or rupture in consequence of distension.

Consequently there existed at the same time in this patient sup-
purative synovitis and deep abscess iif the forearm. The latter was
consecutive to the former, and it is probable, although it has never
been possible to demonstrate it either by the symptoms or by the
autopsy, that the deep layers of the forearm have suppurated after
opening of the synovial membrane, which had it.^lf already auppi
rated, just as in suppurative synovitis of the kuee we often see deep
abscesses of the thigh begin by the effusion of syoovia! pus into the
deep cellular tissue of the limtra.

I do not mean to say that things always occur exactly in this way,
and that all suppurations, starting from any point of the synovial
membrane of the flexors, will end in deep suppurating phlegmon of
the forearm. First, contused wounds of the thumb are not followed
by this propagation as frequently as are those of the little finger.
That ia probably due to this, that, in the subjects affected, the outer
portion of the Isursa is independent and closed, as I told you was
sometimes the case. Secondly, it ia not impossible that the propagated
inflammation may remain plastic and adhesive, although it was sup-
purative nt the starting-point.

II. Synovilis of (he Jlexora, partly siippuralive ; Recovery with de/oT'
mity of the fingers. — In No. iiU is a woman 28 years old, whose occii-
patiou as burnisher obliges her to work a great deal with her hands,
who shows on the palmar face of her fingers a great number of!
calluses and cracks. A fortnight ago there appeared at the end of'
the little finger of her right hand an inflammation, which soon spread
to the hypothenar eminence and thence to the palm of the hand, the
thenar eminence, and the thumb. This inflammation terminated
rapidly in partial suppuration ; the first uoUection opeaed spontatifl-

32a^|

rnicaE^^H
have^^l

S30 PHLEQMONa, ABSCKSS, FJ8TULA.

oufilv at the upper portion of the thenar region: yesterday there waa
another in the hypolhenar eminence, wliich was opened with the
biatonry. A probe introduced intoeilherof these two openings passes
far up in a cavity, which is doubtlesa nothing else than the great
synovial bursa of the flexors. From the courae followed by the in-
Rammaiion this must be a phlegmiisia wliich occupies the commoa
synovia! inembrane of this region.

I think, however, I can show you a notable iliFference between thia
synovitis and the preceding one. In ilie other the whole synovial
bursa bud suppurated ; in this one I showed you that although Hie
palm of the hand was swollen, pressure exerted upon it did not cause
pus to flow from the orifice of the thenar nor from that of the hypo-
thenar eminence. Moreover the quantity which escapes sponta neou sly
ia muuh less than it would be if the collection ocoupied the whole
bursa. Of two things one; either the abscesses have formed by
proximity outside of the great synovial membrane, the cavity of
which has been the seat of an adhesive inflammation ; or else the ab-
scesses have formed within circumscribed portions of the bursa, the
r^sl of whicli 18 filled with false membranous products, the aynovitia
having remained plastic in the centre while it has become suppurative
in the lateral portions.

I cannot determine by clinical signs with whit-h of these two varie-
ties we have to deal. The important point for me is, that there ia at
this moinent a mixture of nonsuppurative with a partially suppura-
tive synovitis or ubsuesses by proximity.

If things remain in this condition life will net be compromised.
But you know that this inflammation is easily propagated to the deep
cellular tissue of the palmar side of the forearm : if it suppurates it
causes at this point a deep aVcess which is very serious, because it
may be complicated by erysipelas, purulent ini'ectiori, or putrid infec-
tion. Our patient's forearm i.s much swollen and doughy, but, it is
not red, and ia not the seat of that pain and tension which indicate a,
deep diffuse phlegmon ; moreover, the general phenomena which
cbaracterize the latter are entirely lacking. There is then bere a
pynovitis, but one which has not suppuralcil, in and beyond the pal-
mar portion of the synovial membrane. What still remains serious
in the case is thia, that this disease will probably end by adhesions
which will interfere with the motions of the fingers: that ia, the
small accessory sheaths of each of the tendons are probably the seat
of a plastic inflammation, which will result in the formation of
adhesions and the abolition ordiminulionof the movements, the fingers
remaining more or less flexed, and flexion itself being very limited by
this sort of anchylosis of the tendons.

I had occasion to show you recently, at the consultation, a patient
who had been treated by a seton for one of those aflections of the
great synovial bnrsa of the flexor, to which the name of crepitant
dropsy has been given. Suppurating synovitis had been the conse-
quence of this treatment. The patient had recovered with the ad-
hesions of which I have just spoken, and came to us with all

AB3CESSE3 OF THE HAND.

3311

ei
■P
ph

wi
thi

fingers linlf flexed and inciipnble of being extended, in short, in the|
concJition described ns ^be daw band.

Now, if Bnppurjiting synovitis of tbe flexors habitually produceH
this result, (io not forget that a simply adhesive or plastic synoviti^
may also do it. You have bad quite recently an example of this
man in whom the synovitis stunting from a contused wound oFj
thetbumb, had suppurated in it and in the thenar eminence, but notf
in the pnlm of the hand and the little finger, "Nevertheless, the i
ments of flexion and extension were very limited, and, as the nfi'ection J
bad commenced two months beFure, I expressed the fear that tbe j
adhesions were too solid to yield to the frictions and sulphur baths'!
which I prescribed.

To return to our patient, I describe her situation in reminding yom
that she bus to flay a tendinous synovitis in tbe thenar and liypo
thenar eminences which has snppurated, and the beginning of a diPj
fuse phlegmon propagated to tbe deep layers of the forearm.

Thernptulical I'ndicaliovs. — They result quite naturally from tha-f
possible consequences of the synovitis which I have described.

We should first try to keep tbe phlegmasia within its present limitH/B
that is, prevent it from invuding in a suppuraiive form the whole oS|
tbe synovial bursa, if, as I have reason to think, ihe suppuratioi
occupies only a part of it, and if the inflammation, orifiinally plastiOj^
has profJuced adhesions in the centre of the cavity which have pre-
vented the pus from filling it. We must then make every effort to
get resolution of tbe phlegmon which is beginning in the forearm,
and, finally, if we obtain these first results we Bhali have to combat

le deformity and the functional lesions caused by the adhesions, A

This then is what we shall do. The openings will be dressed wilhfl

■rale; then we shall envelop the hand and forearm in cotlon-andl
ipply a moderately tight band. In a word, we shall treat the diffuse
phlegmon by compression. The patient will keep the bed, the limb
will be kept immovable upon a chaff bag, the hand a little higher
than the elbow.

The compressive bandage will be renewed every day on accouat.J
if the suppuration, and to see if deep fluctuation appears in the fore-.l

Afterwards, if things go on happily, we shall prescribe sulpbm
baths, and have prolonged frictions made with lard or beef marrow,-^
morning and evening, together with movemenia carefully communi-
cated to all the fingers, so as to favour reaoUition of the plastiumate-^
rfals which form the adhesions. We shall employ, in short, treulmenl.^

.alogous to that of incomplete nrlicuhir anchylosis,

(Tile suppuration remained limiteil to the points which it occupied

the beginning, Eesolution took place in the forearm ; but flexion-*]
ind extension of the lingers were sldl very incomplete when the-^

.tient left the hospital alter two months' sojourn iu it.)

332 PHLEGMONS, ABSCESS, FISTULA.

LECTURE XLI.

SUPERFICIAL AND DEEP DIFFUSE PHLEGMON OF THE FOREARM.

1. Two cases of subcutaneous diflfnse phlegmon of tlie forearm, one with erysipela?,
the other without erysipelas — Termination with rigidity, probably temporary,
of the fingers and the hand. II. Deep or sub-aponeurotio phlegmon of the fore-
arm, consecutive to a suppurative synovitis of the flexor tendons — Two theories
to explain the propagation of the phlegmasia : that of synovitis, and that of deep
lynjphangitis — Termination by recovery with the deformity known as the claw
hand.

Gentlemen : I. I spoke to you a few weeks ago of two patients
a fleeted with snbeutaneous diffuse phlegmon of the back of the hand
and dorsal face of the right forearm. One of them, 32 years old,
occupying No. 88, ward SainteVierge, had seen his affection develop
in consequence of an insignificant scratch upon the back of his hand.
He came to us, ten days after it had began, with swelling, redness,
and heat extending from the extremities of the fingers to the shoulder.
Upon the back of the hand and forearm was the doughiness which
characterizes the first period of diffuse phlegmon. The doughiness
of the arm, where the redness occupied the entire circumference, was
much less, and the appearance was rather that of a slightly oedema-
tous erysipelas than that of a diffuse phlegmon. As moreover the
intense febrile movement which characterizes erysipelas existed, I
presented the patient to you as off*ering an example of phlegmonous
erysipelas, or, if you prefer, of diffuse phlegmon with erysipelas,
pointing out at the same time that the diffuse phlegmon occupied the
hand and forearm, and the erysipelas chiefly the arm. The ultimate
course of the affection confirmed my first opinion. Suppuration set
in upon the dorsal face of the hand and forearm ; I made several
long incisions there, from which you saw an abundant quantity of pus
flow, followed a few days afterwards by gray and whitish membra-
nous strips composed of mortified cellular tissue. I showed you, how-
ever, that the suppuration was under the skin, and that it had not
passed through the deep fascia; that no abscess had formed upon the
palmar face of the limb, but that the inflammation had terminated
there by resolution, at the same time that the erysipelatous redness
had disappeared from the arm.

Today, five weeks after the beginning of the disease, the general
condition is excellent, and the wounds left by my incisions will soon
be cicatrized. I have advised the patient to begin now to move his
fingers, either with the corresponding muscles or with his other hand,
for the articulations of these fingers have become rigid through their
prolonged immobility, and their participation to a certain extent in
the morbid process which was developed in their neighbourhood. If

PULEQMON OP THE FOREARM.

Bbould lio nothing for it, tliia rigidity would last for a ]< _
perhaps indefinitely, and we should thus have an infirmity succeedini_
'to the aft'ection, I hope that by the aid of spontaneous and com-
municated movements, to which we shall soon add a little massage,
this rigidity will not last more than two or three months, and I have
the more reason to hope so heiiause the patient is still young, and, as
I have oTien told you, articular rigidities, especially those of the
small articulations, are less rehellious as the patients are younger.

Not far (rom this patient is another one, in No. 41, sixty years old,
who presents an example of a similar affection, that is to say, of a
subcutaneous diftbae phlegmon of the dorsal aspect of the left h»nd
and forearm. But in him we find thi.s dift'erence, that the phlegmon
has been neither preceded nor accompanied by erysipelas propagated
to the arm and body, that the febrile symptoms have not been intense,
and that as the suppuration was limited to the lower third of the
forearm and ihe back of the hand, we have had to make fewer in cieions,
and the suppuration has been less prolonged. Tbis patient also ia
recovering ; but the articulation of the fingers are stifti and I fear, on
account of the age of the patient, that this rigidity will last longer
than in the preceding case.

11. The patient in No. 29, a baker's hoy, 24 years old, hurt the
palmar face of the little finger of his rig}it hand near the articulation
of the first and second phalanges with a saw a week ago. To what
depth did the tooth of the saw penetrate ; was the articulation opened ?
We do not know. Is the synovial membrane of the flexor tendon
interested? It is probable, but we have no proof of it. The patient
continued to work for three days; on the fourth a swelling appeared
in the little finger, the palm of the hand, the thumb, and the forearm;
at the same time general symptoms set in : insomnia, due to the pain,
and fever. The patient, however, had no chilU. To-day we see a
suppurating contused wound occupying the middle of the little finger,
a swelling of the thenar and hypothenar eminences, of the palm of the
hand, and of the palmar fiice of the forearm extending nearly to the
elbow; still the swelling of the hand is small. The forearm is the
seat of a redness which is intense but which cannot be called ery-
sipelatous, because at the beginning there were none of the general
symptoms which precede this afi'eotion: violent chill, intense fever,
vomiting. The redness appeared only after the swelling; and then
it does not extend very far, and is limited to the phlegmon. If it had
been a real erysipelas it would undoubtedly have extended beyond
the tumefied and phlegmonous parts. The dorsal face of the ban)
and forearm does not present, so to speak, any swelling, difi'ering
'this respect i'rom the other two patients.

Can we detect fluctuation? In the hypothenar eminence there \s
a soft swelling, but it is without elasticity. The thenar eminence
presents a considerable swelling; if we compress it with one finger
We feel a mingled sensation of elasticity and softness ; if we place the
two fingers at a certain distance from one another and make pressure
with one while the other remains immovable, we feel a seiisatjon
which reaombles that of lliictuation. But it must be remembered

834 PHLEGMONS, ABSCESS, FISTULA.

that this region gives, in the normal condition, false fluctuation, and
we might almost say that, in phlegmasia, the presence of pus here is
only certain when fluctuation is no longer as marked as it is nor-
mally.

This is the eighth day of the accident, but the fourth of the in-
flammation : it is not probable that there is yet any pus; still, in
order to be certain, I made three punctures with a pin, and without
any result ; no pus came.

Is there any fluctuation in the forearm? I have not found the
slightest sign of it.

This then is a phlegmonous inflammation which has not yet sup-
purated, and, as it is extensive, we may call it a diffuse phlegmon.
In the preceding patients also the affection was a diffuse phlegmon,
but it was subcutaneous, while here it is deep, sub-aponeurotic.

My reasons for this opinion are the following : There is a consider-
able swelling, without the superficial doughiness which is seen at the
beginning when the phlegmon is subcutaneous. We see at the wrist
the raised lines formed by the tendons, and in the middle of the fore-
arm we have that peculiar sensation of softness given by the muscles
through the skin ; but these muscles are slightly tense, and as if raised
by something behind them. All these signs indicate a deep inflamma-
tion ; and another argument in favour of this opinion is the propa-
gation to the forearm of the phlegmasia starting from the hand. It
is evident that in the latter the inflammation is not superficial ; for by
pressing upon the wrist we can feel the annular ligament and the
tendons, notwithstanding the enormous swelling; now, if the
swelling was subcutaneous these parts could not be felt, and we should
find a superficial tumefaction whicli would mask the rest. For a
moment 1 asked myself if it was not the muscular hypertrophy which
is often found in bakers, but the other arm shows nothing similar.
It is certain then that it is an inflammation : now, so soon as we decide
that the inflammation is not superficial, we have to admit that it is
sub-aponeurotic and submuscular, and that it is situated between the
pronator quadratus and the deep layer of muscles.

Is this development of an inflammation in a finger, and its propa-
gation to the deep parts of the hand and forearm, an unusual occur-
rence? Not at all. I have had occasion to show you several similar
cases, and a year never passes without our having two or three ex-
amples of it here. You have not forgotten the explanation which I
gave of these facts : the suppurative inflammation starts from a finger
(the thumb or little finger) to the extremity of which the main syno-
vial bursa of the palm of the hand extends. It is propagated to the
latter, and thence to the deep cellular tissue of the forearm, by virtue
of a peculiar aptitude possessed by the subcutaneous and tendinous
synovial bursa to transmit to the surrounding connective tissue the
phlegmasiae, and especially the suppurating ones, of which they
become the seat. I remind you also that I showed in this amphithea-
tre a specimen in which the course of the suppurative inflammation
within and beyond this tendinous synovial bursa was very evident
(page 827). It is true that since I showed you that specimen another

PHLEGMON OF THB FOREARM.

33™

explanation has been offered. Prof. Dolbeau' thinks that the starting
point of these deep phlegmona of" the forearm is a lymphangitis of
the deep lymphatic vessels which accompany the arleries. He bases
his opinion upon this incontestable fact, that the suppuration eome-
times appears in the forearm without at l.he Bame time occupying the
hand and the whole length of the finger in which the affection began.
I have sought, on other occasions, to explain this peculiarity by tell-
ing you that the inflammation propagated from a finger to the syno-
vial bnrsa and to the deep cellular tissue might renlain plastic op
adhesive at some points and might snppurale at others.

Furthermore, I offer four objeetions to Professor Dolbeau's theory :
1st. It cannot be proved unatoniicaJly. 2d. It supposes that the sub-
aponeurotic abscesses must be along the course of the radial and
ulnar arteries, that is, not very deep, for it is there that we find
the principal aub-aponeurotic lymphatic vessels. The abseessea which
we see in ihese eases are very much deeper; they are found in front of
the pronator quadratus, of the inter-osseous ligament and oT the hones,
which are sometimes denuded in consequence of the partieipation of
the periosteum in the disease; now, at this depth there are very few
lymphatic vessels, only those which accompany the interosseous
artery, and they are very small and too few to cause such large

f)hlegmons and abscesses. Notice what occurs after superficial
ymphangitea. The afl'ected lymphatic vessels are very large, anil
■yet only circumscribed ahscesses form about ihem. 3d. M. Dulbeau's
■theory does not explain why deep abscesses of the fnrearm occur so
'habitually after deep wounds of the thumb and especially of the little
finger, and only very exceptionally after wounds of the other fingers
■whose synovial sheaths are independent of the main synovial bursa of
'the wrist and palm of the hand, 4lh. Finally it does not enlighten us
upon the causes of the gravity of the prognosis in these cases, of the
adhesions of the tendons, the insufRciency of the movements of the
fingers, the elaw hand ; all those phenomena which can hardly be
explained except as phenomena consecutive to a tendinous synovitis.
I willingly believe, for it agrees very well with what we see in the
superficial layers of the limbs, that a deep lymphangitis intervenes in
cases of this kind, that it is one of the means of extension of the
phlegmasia, that perhaps even it is that which propagates it some-
times to tlie main synovial bursa. But I want you to admit at the
same time the esisietice of a synovitis, either plastic or suppurutive;
I consider it important, because with this notion, proved to be true
by autopsies, is associated that part of the iberapeutica the object of
which is to combat the tendinous rigidities as soon as possible, and
to diminish, if it can be done, the deformity and the functional trouble
which their persistence occasions.

At the present moment, tlien, two things preoccupy us in this case :
Ifit. The imminence of a deep or inlermt/scular suppuration in the
hand and forearm, and the possibility of a septicEemia; 2d. The coor

as, eoa^veatxts aux blMf

836 PHLEGMONS, ABSCESS, FISTULA.

secutive deformity, a deformity all the more serious since it will
occupy the right hand.

As for the treatment, I can hardly have recourse to anything
except rest, poultices, and narcotics. I thought of making compres-
sion, but the swelling and redness are so great that I fear it might
cau8e strangulation and gangrene. Moreover I must examine this
swelling every day and open it soon as I find fluctuation.

The young man in No. 29, who had had the little finger of the
right hand wounded by a saw, presented, 48 hours after I had spoken
about him, distinct fluctuation in the anterior part of the hypothenar
eminence. The next morning I felt a deep fluctuation in the fore-
arm, a fluctuation the limits of which were the radio-carpal line below,
the junction of the lower and middle thirds of the palmar aspect
above. I sought carefully to see if the wave could be sent from the
forearm to the palm of the hand, as should have been the case if the
purulent collection occupied both the tendinous bursa of the wrist
and the deep cellular tissue of the forearm. I did not find it to be so.
Furthermore, pressure upon the forearm did not cause pus to flow
from the opening made in the hypothenar eminence, nor from that
made by the injury in the little finger which still suppurated. It
seemed then that we had three separate suppurations. This circum-
stance was favourable to M. Dolbeau's explanation by deep lymph-
angitis, along the course of which the abscesses might form here and
there without communicating with one another. Admitting propa-
gation by synovitis, I presume that, in this case also, the synovial
membrane has not suppurated on its inner face, and has been the seat
only of a congestive and plastic inflammation, but that the cellular
tissue of the hypothenar eminence and of the palm of the hand, to
which it has transmitted the inflammation, has taken part in the sup-
puration.

However that may be, experience having shown us that these deep
abscesses, when once formed, have more tendency to burrow and
spread along the deep layers than to approach the skin, from which
they are separated by very thick muscular and aponeurotic layers,
I told you that we must not temporize, and that as soon as fluctua-
tion could be felt, an incision must be made.

Still, as it was necessary, in order to reach the collection, to
traverse the superficial and deep layers, I completed my diagnosis
by means of puncture and aspiration with the Dieulafoy syringe.
After I saw the pus flow into the aspirator I ansesthetized the pa-
tient with ether and made, layer by layer, an incision two and a
half inches long along the middle of the forearm. M. Dolbeau, in the
article of which I have spoken, advises two incisions to be made,
one along the course of the radial artery, the other along that of the
ulnar, that is, in the points where the lymphatic vessels are to be
found which are the starting-point of the abscess. But as this collec-
tion was much deeper than the arteries, as it corresponded much more
to the centre than to the sides of the forearm, as, on the other hand, I
wished to be sure of avoiding hemorrhage, I made my operation as
upon other patients, and notably as upon the one of whom I spcike

I.EQMON OF THK FOREARM.

337

]a»t yeiiT (page 328), that is, T used a bistoury to gel tlirough tlie fascia,
nnd tlien my fingers to tear through the muscular interstices. The
following days I had some difBciilty to get a free escape for the [lua,
notwithstanding the use of bundles of lint and drainage tubea. Every
morning and evening I had to separate the muscular interstices anil
make injections of carbolized water, as much to prevent the stagnation
of the pus as to disinfect the deep pouch.

Wc had no dangerous general symptoms. After the fourth day
the flow was freer, but I continued the injections morning and night.
The patient was sustained by nourishment and tonics. During ihe
treatment I often tried if pressure upon the palm of the hand would
make the pus flow from the openings, but it never did so, and I con-
tinued to think that the synovitis had not suppurated in the palm of
the hand, as is quite often the case in cases of this kind.

In this connection, I remember an old woman whom I treated at
the Hflpital Cochin, and who also had a deep phlegmon of the hand
and forearm originating in a wound of the little finger. She suc-
cumbed to a putrid infection, and I found suppuration, not only of
the great tendinous synovial membrane of the wrist and forearm, but
also of all the carpal articulations, to which the suppurated phleg-
masia starting from the tendinous bursa had been propagated.

To-day all is cicatrized, and our patient is cured of his suppuration,
but he has not recovered the use of the limb; the tendons of the
fingers, bound down by adhesions, no longer permit either flexion
or extension except within very narrow limits. You saw that the
fingers were half flexed and that the patient could not extend them :
he cannot complete this imperfect flexion and cannot close the thumb
entirely against the other fingers. In short, he presents the claw
shape of which I have spoken several times.

Will this condition of things disappear? I hope that it will di-
minish, because it seems to me that the adhesions ought to be less
numerous and less rebellious when the inflammation has remained
plastic, at least over a great extent of the synovial membrane, than
when it has become suppurative and the membrane has granulated,
I hope 80, especially if the patient will follow our prescriptions, that
is, will tiike sulphur baths, make prolonged frictions, massage, and
communicated movements. I make all these recommendations, but
am not able to oversee them myself, for he is tired of the hospital
and intends to leave us in a few days.

■ 888

888 PHLEQSIONS, ABSCES3, FISTULA.

LEGTUBE XL II.

DENTAL ABSCESSES AND FISTDL^.

1. Suppurated i^nbmaxUlarT' aienn-phlesmoii — Mode of formatfou — CommenDenieDt
hj an adenilis consecntira to a l^mphangilix etlhar of tlie palp of tiia tooth or
of the Blveola-dental perioateiim — Obaourity upon this pniat becanee anslomiali
have uot snfiioieiitly studied the d ant nl lymph atio vessels. II. Pblegmon aud
dental absotss uiider the gum of the upper jaw — Probability of conaucntiTe
alveolar opcrosis — Utility of tba removal of the decayed tooth, IIL Cntanwiu
dental Satola kept up by caries of the second upper molar of the right side with
an Induratud course extending from the flstnia to the tooth. IV. Submasse-
teric abscHBS of dental origin — Quite esleufllva conseautive alveolar necrosis —
Peculiar gravity of these absoeSHea — Their possible prolongation to the terapor»l
region — Consecutive pumlent infection — Noceaaity for large openings and wash-
ing out.

Gentlkmen: We have recently liad four patieots affected either
wilh abscess or fistula conaeoutive to caries of a tooth, and it will be
sufficient to mention thein to fix in your minds the principal varieties
of suppuration of dental origin.

I, Suppurated submaxillary adeno-phlegmon. — The patient who ia
now in No. 20 shows you a quite common type. She is twenty-four
years old, blonde, slightly lympliatie, generally enjoys good health,
and has never had any scrofulous manifestation. She is not pregnant,
and has never had any children. She knows that she has caries of
the second molar of the left side of the lower jaw, and she has some-
times suS'ered from it, but never enough to decide her to have the
tooth drawn, or, what would be better, to have it filled. More
recently she has again suffered some paiu in it which has prevented
her from chewing her food upon that side; then, five days ago, she
felt a rounded and painful tumefaction at the upper part of the neck
under the edge of the lower jaw, and a little in front of its angle.
This swelling increased and was accompanied by a febrile movement
which compelled her to enter the hospital.

You found at first a uniformly rounded swelling of the super-
hyoid region, rosy in colour over a great extent, and of a deeper red
at one point where the consistency was less than at others. There
was heat appreciable by the hand, spontaneous shooting pain, and
pain on pressure. The jaws were kept closed by a contraction of the
muscles which prevented examination of the teeth.

After a few days fluctuation could be felt; I made as small an ia-
oision as possible, about half an inch loug, not wishing to cause a
large cicatrix. A small quantity of good phlegmonous pus escaped,
but there still remained a pastv tumet:iction formed by a considerable
part of the inflammatory swelling which had not yet advanced to
Buppuration.

DENTAL ABSCESdKS AN

The following days, while the pus flowed from the wounc!, the lips
of which were kept apart by a etrlp of frayed linen, this swelling
diminished and terminated by resolution. To-daj', the seventeenth
day since the operation, the cicatrice is formed, there is no fistula, the
patient can separate her jaws and eat. By placing her before a well-
lighted window, I could easily see a carious loss of substance in
I the second lower molar. As it would be difficult to fill the tooth, T
advised the patient to have it drawn, and warned her that if she did
not consent she would be exposed to a renewal of the suppuration.
But, as she does not suffer, she refused for the present to follow my
advice, and I did not urge it.
' Permit me now to explain the mode of formation and the course
of this abscess, in what points it resembles the others of which I shall
presently speak, and in what it differs from them.

It resembles them, first, in its starting-point, which was evidently
the affected tooth. I do not mean by that to say that all inflamma-
tory submaxillary abscesses are caused by carious teeth. There are
some, and I have shown you examples of them during the year, which
are consecutive to an affection of ifie mouth, others which start from
aaore throat, that is to say, they may be caused by inflammation of
any of the parts which, like the teeth and guma, send their lymphatia
vessels to the submaxillary ganglions. In this case I believe in the
dental origin, because it is the most common, and because I found no
inflammation in the throat.

It difters in its mode of formation; for, among the phlegmons of
dental origin, there are some which, having begun in the periosteum,
confine themselves to the neighbouring cellular tissue, and sometimes
to that which is more or less distant, and the lymphatic vessels have
no part in the development. There are others, on the contrary, in
which the inflammation first affects one or several lymphatic ganglions
and then Is propagated to the cellular atmosphere surrounding them,
as takes plaoe in other regions, and eapeeialiy in that of the groin,
during the formation of most of the acute bubos consecutive to non-
infectious chancres.

It is with this latter form, which you have often heard me designate
by the name of adeno-phlegmon, that we have to do here. For the
affection did not commence on account of the proximity itself of the
tooth, as is the case in phlegmons of periosteal origin; it commenced
at a distance in the suprahyoid region, which I also call the sub-
maxillary, there where, you know, lymphatic ganglions are found in
considerable numbers, most of which are inclosed within the sheath
of the Hubmaxiltary gland, and receive lymphatic vessels from the
cavity of the mouth, and especially those of the teeth and gums of
the lower jaw.' Further, the trouble began by a rounded, rolling,
I painful lump, like those formed by acute adenitis; then, in a second
■ period, this rolling tumour was found enveloped in a uniform mas^j
1 which was the surrounding phlegmon.

1 t«eth of the upper Jatr oommanicata tfitli tU*. I

1
I

I
I

8i0 PULEGMONS, ABSCESS, FISTULA.

TIlis abaeesB differed, alao, from others by its mo<le of term I nation,
It hna left neither fistula nor necrosis. You remember that the liay
after the incision I introduced a probe into the wound, and that I
felt no cJeniidiitioTi of the jftw at any point. I should undoubtedly
have fell it if the starting point had been an o.steo-peri ostitis; for, in
such a ease, the periosteum is almost always destroyed or stripped
offj and the nuked bone can be felt. The ultimate course corresponileii
to this examination, for there remained no fistula, such as often
persists after denudation, fistula due to the non-reproduction of the
periosteum and consequent necrosis of the maxilia.

Events proceeded as follows in this patient. The dental palp
became inflamed about the caries. If I were sure that this pulp has
lymphatic vessels, I should say that they had transmitted the inflam-
mation to one of the submaxillary ganglions, and that this inflam-
mation bad been propagated to the surrounding cellular tissue, had
become phlegmonous, and taken on the suppurative form.

But there is here a nesc/oyuirf which often intervenes in pathogeny.
Many subjects have carious teath without having adenitis; many
have simple adenites which do not become phlegmonous, do not
suppurate, and terminate by resolution. Some indeed, and we have
lately had an example of it, have the adenophlegmon, but it termi-
nates by resolution instead of suppurating. Now, we are never able
to find the particular cause, under the influence of which the inflam-
mation, starting from the pulp of the tooth, transmits to the ganglions
an inflammation of one form rather than of another. It is always the
question of individual aptitudes, varying with the subject, and with
the moment in the same subject; a question which is surrounded
with obscurities which render it everywhere insoluble.

Next, to admit a starting-point in a lymphangitis of the pulp of
the tooth, we must be certain that lymphatics exist in this pulp. As
for myself, I have never seen them, and I do not know if others have
seen thejo. M. Sappey, the most competent of our anatomists upon
this point, does not describe lymphatic vessels of the teeth; he men-
tions only those of the gums, and, according to him, those of the
lower jaw empty into the submaxillary ganglions, those of the upper
jaw into the deep parotid ganglions. I admit that I am nevertheless
disposed to believe in the existence of lymphatics of the pulp, accord-
ing to the facts furnished by the clinic. The submaxillary ganglions
become painful so easily and so promptly after caries of the lower
teeth that it seems to me difficult to e.\plain without a lymphangitis
originating in the pulp. If it is not the latter which i& at fault, it
must then be the lymphatic network of the alveolo-dental periosteum,
which is better demonstrated, I believe, than that of the pulp; or,
perhaps it is that of the gum to which the affected tooth may have
transmitted its inflammation; but I should then be surprised to see
so often submaxillary adeno phlegmon without appreciable gingivitis.

And, since the occasion has presented itself, 1 point out to you
another peculiarity. We very rarely sea adenophlegmon caused by
affections of the upper teeth. Is it because the lymphatic network.

^ DENTAL ABSCESSES AND FISTULA. 341

either of the pulp or of the alveolo- dental periosteum, is too small ?
or is it for some other reason ? I (io not know.

But !et UB return to the practical sUmlpoiiit. My principal objeet
JD insisting upon this sabject has been to make you understand,
gentlernen, that, nmoiig the abscesses of dental origin, there are some
which are not followed by denudation, necrosis, or fistula, and which
may get well without removal of the tooth wliich caused the affection.
For, if I advised this woman to have her tooth drawn, it was not to
cure the absceea or its consequences; it was only to protect her from
a return of the same trouble, or from another of the same kind.

11. Subgingival denial phlegmon and abscess of the upper jaw. —
You saw yesterday at the consultation a man who had had pain for
several days, about one of those fragments of a carious molar which
we call stumps, and in whom a painful swelling of the gum over
this stump had appeared. As the swelling of the gum was tense and
di.stinetly fluctuating, I at once cut it, taking the necessary precautions
not to wound the lips with the blade of the bistoury while doing so.
I opened it freely, because wounds of the mouth have a great tendency
to dose too soon, and there was reason to fear, in case cicatrization
took place before the occlusion of the pouch, that the latter would
again fill up.

The pus which escaped was mixed with blood and had a fetid odour,
which is quite common in abscess of the cavity of the mouth.

This abscess resembles, by its origin, the one previously described.
It was certainly an inflammatory process, starting from a carious
tooth, that caused it. But with respect to its position, it differs in
two ways: first, it was not developed so far from its starting-])oint;
and, secondly, it did not begin by tha lymphatic element. In this
connection I wish to remind you of one remark: dental adeno-phJeg-
mon arising in the lower teeth is not rare in the lower jaw ; we see
it arise much leas frequently from the upper teeth. When caries of
the latter gives rise to it, the inflammatory swelling ought to appear
in the parotid region. But the clinic has not enlightened me very
much upon this subject, because, in the rare parotid ade no- phlegmons
with which 1 have met, with the exception of one case in which it
was certainly due to caries of an upper wisdom-tooth, I was never
able to determine positively if the starting-point of the initial lyra-
phangiiis had been in the teeth or in the mouth.

In this case it is probable that llie inflammation starting from the
affected tooth first gained the alveolo-dental periosteum, then the ex-
ternal periosteum, and the cellular tissue between it and the mucous
membrane of the gum. It is then a suligingival and periosteal phleg-
monous abscess. It is, however, possibla that the pus may have
formed under the periosteum, and that consequently the abscess has
been subperiosteal. This is all the more probable because, after hav-
ing made ihe incision, I passed in a probe and found part of the
upper maxillary bone denuded. Still, I do not know, and fortu-
nately it is without much importance, whether the periosteum has
been destroyed because the abscess formed below it, or consecutively
to the suppuration of its outer surface. It is the same here us in

842 PHLBSMOSS. ABHCESa, FISTOLA.

acute Bubperiosleul obficesaes of the large long bones; we know tW
periosteum disappears or is stripped oft' in consequence of these phleg-
mnstce, but we do not know exactly which of these lesions has been
produced, nor, above a!!, what has been the course and the suocesaion
of the phenomena.

The denudation warned us of one thing, that necrosis was possible.
I say possible, and not certain, for in such cases we sometimes see
the hone cover itself again and continue to live. But if the decayed
tooth remains in its place, it causes another abscess after a cerlaio
length of time, a new denudation, and, if the necrosis does not then
take place, it does on the third or fourth attack. It is to be remarked,
moreover, that in these cases of gingival abscess the necrosis is goner-
ally limited to a circumscribed point of the alveolus, and is never
very exiensive; and that at the same time the concomitant osteitis
does not become hypertrophic in the neighbourhood, as you know that
it does in the long bones.

What will this abscess become? If the osteitis is not yet necrotic
it will close, and everything will resame the condition in which it
was previously, that is, the patient will keep his stump and will
almost inevitably have the relapse of which I have spoken. If, how-
ever, necrosis has already occurred, and elimination must take place
in the form of dust or of a splinter, suppuration will be kept up and
the fistula will last until this resnlt is obtained; now this does not
take place, or at least it is not definitive, nntii the affected tooth has
been removed from its cavity, a process which is always slow when
it goes on spontaneously. We have recently seen at the consultation
a woman who has had for nearly a year a fistula of this kind (gingival
dental fistula) kept up by a very limited spot of necrosis on the
lower jaw corresponding to a carious and loose canine tooth.

These fistulse, which are very common, are not serious; but they
keep up an unclean and inconvenient suppuration in the mouth.

To relieve the patients of these inconveniences: return of the ab-
scess, slowness of elimination, and persistence of the fistula, there is
only one useful advice to give them, and that is to remove the tooth
or the stump which is the cause of the trouble. Whether it be that
the operation itself removes the necrosed alveolar portion, or that the
opening of the alveolus prepares an easier way of elimination, it is
none the less true that after the removal of the tooth the suppuration
and the fistula, if there is one, disappear promptly. I have given
this advice to our patient, and he has followed it. The root of the
carious tooth has been removed, and I consider the recovery assured.

Ill, Outa^ietms denial fistula kept up by the second iipper molar on the
right side, with a callous band between the fistula ajid the tooth. — In con-
nection with the preceding case I spoke of gingival, and consequently
intra-buecal, fistul® consecutive to abscesses starting from decayed
teeth and the alveolo-dental periosteum, with imminence of necrosis.
But it happens sometimes that abscesses of this kind, instead of pro-
jecting simply under the mucous membrane, open through the skin
and cause cutaneous fistulro which are much more disagreeable to the
patientSj since they occasion an ugly deformity. You will meet with

f DENTAL ABSCKS8ES AND FISTULA. 343

these OS teo- peri OS teal abscesses followed by cutaneous dental fistulie
upon the upper jaw as well as upon the lower. In the first ease they
open upon the cheek, in the second upon the outer face of the lower
jaw. Generally the concomitant necrosisMs still very limited and
will promptly disappear after removal of the tooth, removal which
will ulways be the principal means of treatment. But in some excep-
tional cases, the necrotic osteitis having spread very far, you will
have a more extended and slower necrosis, the elimination of which
will only take place long after the removal of the carious tooth.

In the case which we have just seen at No, d, ward Sainte Vierge,
the cutaneous dental fistula is made remarkable by the existence of a
very hard callous band which cleared up the diagnosis, and by the
opposition which the prolonged contracture of the muscles which
close the jaw oft'ered to the examination of the teeth and the neces-
sary removal of one of them.

It is a man 33 years old, very subject to toothache, who seems to
have had gingival abscesses on several occasions. Seven weeks ago
a new abscess opened spontaneously on his left cheek in front of the
maaseter and at the outer portion of the canine fossa, and remained
fistulous.

You saw that the orifice, depressed in its centre, was surrounded
by vegetations, and that it yielded a small amount of serous pus.
This liquid was not as limpid and did not flow in as large quantities
when he was eating, as it would if it had been a salivary fistula. A
probe introduced into the fistula passed towards the upper jaw, and
although I strongly suspected necrosis I did not find the characteristic
hard and sonorous point.

The fistulous canal was about an inch long. By placing a finger
in the mouth upon its course, I felt an elongated induration, which
certainly corresponded to it. Seizing the cheek between the thumb
and forefinger, one of them being placed within the mouth, the other
upon the skin, I still better appreciated the elongated, hard, evidently
callous cord, extending from the cheek towards the hindermost part
of the upper alveolar arch. I called your attention especially to this
callous cord; I told you that it was found almost always in cases of
cutaneous dental fistula, that it was not very appreciable when the
course was short, but that it was much more so when it had a certain
length, I added that it was a great help to the diagnosis, because it
indicated the certain existence of a carious toolh and necrosis, and
the point where these lesions were to be found.

This double indication was all the more precious in oar patient,
because the probe did not reach the necrosed bone, and the explora-
tion of the mouth was rendered impossible by the constriction of the
jaws. This constriction, which is seen rather during the acute period
of dental phlegmons than during the chronic and fistulous period
with which we have to deal here, is more often met with when the
last two teeth are involved than when the others are. In the absence
of certain signs, all the others — the existence of a callous tract, its direc-
tion towards the posterior portion of the upper alveolo-dental arch, con-
traction of the muscles — united to make me believe in the existence

844 PHLKGMOX3, ABaCEas, FISTULA.

of an nlveolo- dental lesion corresponding either to the wisdom- tooih
or the second upper moliir.

Theindicntion was precise; to open the mouth, examine, and remove
the tooth that was found to be nft'octed. I should have temporized if
the inflammation had still been in the acute state, lor, at such a time,
the attempts to separate the jaws by force sometimes cawae an ex-
acerbation of the phlegmasia, and, moreover, it is difBcuU to succeed,
because tbe muscles are too firmly contracted. But in this case there
was no acute inflammation, it was yirobable that the resistance was
nut great, and it was necessary to prevent the contraction, which was
atiil curable, from giving place to an incurable retraction.

That is why I first, took a spoon and passed its handle, on the flat,
between the two rows of teeth, and then tried to turn it on its edge,
80 as to separate them. I did not entirely succeed, but I obtjiined a
separation of a few lines. I told the patient, who for some time had
been able to eat nothing but soups, and was anxious to have the
functions of his jaws restored as quickly as possible, to use the spooD
in the same way, live or six times during the (.lay.

The next day I found the separation a few lines larger, and then
substituted fur the spoon the conical screw of boxwood, which I
first introduced myself, so as to show the patient how to use it. At
the end of three days enough separation bad been obtained to allow
me to discover, with the aid of a dental mirror, a deep caries behind
the second upper molar, which was a little loose, and whose alveolus
suppurated. I did not see the point which was necrosed, but the
intra alveolar suppuration left me no doubt of its existence.

The tooth was then drawn. Four days afterwards the cutaneous
fistula closed. To-day, the callous tract commences to grow smaller,
and I count upon a definitive recovery.

IV. Suhnmsseleric phlegmonous abscess of dental origin. Necrosis
of the lower jaw. — Gentlemen, a young man, 2;i years old, who was
for a long time in No. 43, ward Saiiite Vierge, and who retorns to
consult us from time to time, came to see us again this morning. On
examining the interior of his mouth, I found, in the place of the second
molar of the right side of the lower jaw, which I had removed two
months ago, an alveolar cavity full of pua, with a denudation and
sonority of the whole cavity and of the internal and external faces of
the maxillary bone, over a surface of about one-third of an inch.
There is then necrosis, but it has been preceded by a peculiar variety
of abscess, of which I will now recall the principal details.

"When he entered the hospital, about two months ago, this young
man had had for seven days a painful and quite hard swelling of the
right cheek, without redness and with a little fever.

He was unable to open his mouth, on account of a prolonged con-
traction similar to that of the preceding patient. At first I was not
able to determine the condition of his teeth. But I felt with the
finger a few asperities and inequalities upon tlie crown of the first
and second molars of the lower jaw; I had, moreover, recognized
that the wisdom-tooth was well out, and that consequently this was
not of those aft'ections which are sometimes caused by the difficult

CENTAL ABSCaSSKa AND FISTULA. 345

and labonoDS evolution of that tooth. Esamining as well as
the posterior portion of the entrance to the mouth, I saw pus flow
from the neigh bourhooil of one of the last molars, and I thought that
it was a deep gingival abauess, the opening of whiuh announced the
approaching termination in a definitive cure or in necrosis. Still
there remained a considerable swelling of the region of the niasseter,
and prcHBure exerted upon this region caused a good deal of pus to
flow from the opening in the gum. We had then a deeper and
more extensive abscess than those which we ordinarilv see open in
the neighbourhood of the gum, and I had to su]>pose that the spon-
taneous opening was not sufficient. Not only was it not sufficient,
but it even closed in a (ew days, and then the swelling became greater
in the region of the masseter and advanced evidently towards the
temple. Then deep fluctuation became apparent in the first of these
regions; I then made a transverse incision an inch long, parallel to
and below Steno's duct, and, also parallel to the principal branchea
of the facial nerve, some of which I should certainly have cut if I had
carried the bistoury vertically. I divided, layer by layer, the sliin
and the whole thickness of the mncseter, and it was only when the
deep face of the latter had been divided that we saw a large amount
of fetid pus escape; pressure exeried upon the temporal region, which
was tumefied even then, did not cause pus to flow from the opening,
ihuB proving that the phleamon, although pro|)agated to that region,
had not yet suppurated there. The probe introduced through the
wound reaeheii the outer face of the branch of the inferior maxillary
bone, but did not allow me to detect any denudation. After this
operation, the pouch, which was kept open by means of strips of
frayed linen, emptied itself little by little, the temporal swelling dis-
appeared, and the jawa could be opened, thanks to the aid of the
conical screw. Meanwhile, the opening in the gum was re-estab-
lished, and suppuration persisted on that side, while it ceased and
cicatrization took place in the cheek.

What was there peculiar in this patient, and in what did his dental
abscess dift'er from those of which I have already spoken ? It differed
in this, that, starting from an affected tooth and its alveolus, the
inflammation was propagated along the periosteum, as in gingival
phlegmons; but instead of stopping in the gum, or burrowing in the
eubmiicous and subcutaneous cellular tissue, it made its way along the
outer part of the j^iw as far as the deep (ace of the masseter, and further
to the sheath of the tfimporal muscle, moving along the coronoid
process to the outer and perhaps the inner face of this muscle. The
phlegmon thus propagated became submasseteric and temporal, al-
though I cannot ray whether, at this latter point, it was subtemporal
or was limited to the connective tissue placed between the muscle and
the aponeuroses. Then the eubmasseieric abscess formed, and, at the
same time, the temporal portion of the phlegmon terminated by reso-
lution. Finally, the submasseteric abscess terminated without fistula,
and without necrosis of the brunch of the maxilla. Only the portion
of bone adjoining the carious tooth necrosed. We recognized, alter-

84S

PHLEGMONS, ABSCBSS, FISTULA.

warda, tVint this affected tooth was the second lower molar, aod we
removed it.

hia was not the first time I had seen deep tempo ro -sub ma^aeterio
phlegmon follow dental caries. In two oF ray private patients the
suppuration invaded not only the sub masseteric portion, but also the
subtemporal portion of the phlegmon. I considered it necessary lo

':e two incisions, one through the temporal, the other through the
moaseter muscle, and to pass a drainage tube from one to the other,
. in order to assure the evacuation of the collection. In one of the
patients, the incision of the temporal muscle occasioned a Row of
arterial blood, which rendered a rather laborious ligature necessary.
Both patients recovered without necrosis of the branch of the maxilla,
and did not even have the alveolar necrosis which we observed in
our last patient.

Things did not pass so happily in a man whom I treated at La Piti^
in 1867. After the submasseteric collection had been opened, purulent
infection occurred and caused death. I did not find the maxilla de-
nuded to !L very great extent, nor its parenchyma in suppuration ; the
purulent infection seemed to me to have been caused by septicEemia
consecutive to the decomposition of blood and of pus in the deep
pouch.

The possibility of this complication authorizes me to tell you that
the indication in abscesses of this kind is to open early and freely,
and in both regions (of the masseter and temporal), when fluctuation
can be sent from one to the other; in one alone, the first, when the col-
lection remains exclusively submasseteric. Stagnation, and conse-
quent decomposition, of the pus in the bottom of the foyer must be
afterwards avoided by means of repeated washings.

As for the patient, we have only to wait for the elimination of the
necrosis of the lower jaw, which is more extensive than usual, but
still quite limited, and to advise frequent washings of the mouth, so
as not to allow the pus to be swallowed.

^^^^^^^^n^^^^^^^^^^H

H 1 BSCESS, acute subperiDst«!Ll, 49

(ermiDaiion wUbout Bapparation,

103

H metnsUtic in pjEcmm, 237

*iih oBleitis and neoroaia,

H neiehboaring. orbj proiimily, 41, 811

103

■ 246

bj marrow of bones, 233, 243

trealiDent aRer suppuratiou hn«

Adoleaoence, period of, 1

begun, 107

115, 186, 268

107, in, 112, 114, 132, IBU, 211,

^_ AnohjloBis of knee, S9, 295

227, 236. 327

^L„&ppBTBtii9, for fracture of olnTicle, 208

of skull, case of, 216

^H- of leg, open und emeloplDg, 87

of an eioEloBiP, ease of, 17

^m of pnlellB, 148

Consolidation after fracture of shaft of long

^m of tbigh, 165

bones. IsC period, 63

^H immoTabte, 88

2d period. 66

^H&Ttbritis, Rfter fracture, 129, ISB, 1B6

^m' ohronic. 298

effect upon the anda of the bona,

^M - dr;nDddefor>nmg,314, 321

^H fonr laricCien, 320

in over-ridiag fructures, G8

^H etiology, 820

8d period, 68

^H trenlmont, 321

condensing osteitis, 69

^H fungoid, 304. Sii Fungoid.

4th period, 70

^m gonnoi-rhaeaT. 2S0

^V in p;«imia, 289

synovitis of tendons, 70

^K osteo-urtliritia, 60

mnBcnlar atrophy, 71

K- Theumitio, 326

CoDBolidation after fracture of eitremilies

H spontaneous, 290, 323

of long bones, 72

H traumatio, 285, S22

^H modeaor termination. 28S

peCDlinrities of online, 78

H tberapeutiual iodioations, 289

subsequent Bjuovilia, 74

Consolidation after fracture of the short

and flnt bonea, 74

B TIED, meobanioal, 82.

Consolidatiun after compound suppur all ug

fraotures, 75

Consolidation, dels; of, 132

influence of light upon, 83

^■v

Cotton dreaaing of A. Ou^rin, 266

Crepitofl, methods of ohminiDg, 117

^B in canoellons tissue, 78

Crushing of bone, its influence in the pro-

^H ic compound fracture, 76, 77

duction of deformity, 122, 106, 204

^^V interfragmentar;, 63

^H proiisional and permfioent, 69

I\EF0RM1TY after fraotnro, 126

U influenoe of crushing, 122, 190, 201

^m 115, 186,2118

^H avoidanoo of suppurotioD by oe-

Dental abscess, 338

^M eludentdreasing, 103

^H consolidation after, 75

fistohi, 34'J

H dingnosis, 101

Dextrine bandage, 68

rs«

^H Dlsloisaliou, rules tor niiikii

^H na applied to elbovr, 2

H hip. 2S2

^1 sboulder. 277

^M Sisploaeoieat in frooture,

forsirm, I

PLBOW. dialooalio:

the etiology of phlegmon ot the

EmphjiaeDiii In compoand Tractiire, 112
EzsuiiDiiCion to deteot fritcture, 78
ElOBtoisiB. cpiphysnrj, of development, 14
oomplicftted hy n cjst, 16
onmpound fraolure of, death, IT

etiology. 15

prngiiosTB, IG

ireotniPiit. 16
£xoBtaBia or 7th cervionl vertrhra, 16
Ezostnaie, auhungunl. i>f tue. 9

ioQuence of age in its produolion, 11
of sex, 11

pnlhnlogien! aaiitooiy, 12

Irentinent. 13
Eitenaioa.coatlaaaua, in fracture of thigli,

EMUK. noute epiphysary oxteitia, 45

p»

hypero)!tosiR| 80
Finger, phlegmon. 327

synovinl shenth of, 329
Fistula, dentni, 842
Forearm, phlegmon, 332

Dolhei

Fmctur

Bthea

of oIikYicle by t

FrsolUMot femor. ehntt.
di'^ICnaBia, 1,55
progTiosia, 168

progno

175

capsular, 108

oapsntii

fraotore, witli res
fuDctioiis; autopsy, ITT

aitople Buprn-oondyloid, 180

ayinptomB, ISO

prognoals, 182

treatment, 183
Bupra- and inter-ooiidjloid, 1R4
riclure of femur, Hpouiaueous, 187
ileratiTB, 191

Fracture of the log, at jitaotion
nod middle [hirds.
toelhod of e
with dieplac
rednolion by e:

immovable bniidn^e, 8B

preoRuliona in npplying, (
Fracture of the leg, V- shaped, 90
its pathology, 91
chamcter of the dlaplaoement, iS*

oitli nngnlar projeotiou forward. 6'
Mcrure of the leg, wilb engagf^nient fit
the point of the fragment in the sbin, 100
actureof the leg, bimalleolar, 116
aethod of reduction, 117

progaOBia, 117

Fruclure of th

leg, aupra-mnll

oinr.

difficulty

f re ten

ion of

fragu.

122

of esch

r. 123

Fracture of th

leg. 00

naeoutiv

late

phenom

na, 124

nrthrilia.

deformity.

120

■

delay of oODBolidat

on, 182

hyperoalos

fi. 126

■

mn^cuUp a

irnphy.

ohlitEralion of vein

B, 131

■

Igia, 1-.!

rot.ilioQ

twards

f upper frngmeot.

Fracture of palelln, recovery with wide
separation, 138

Btuily of the functiotLB of the limb, 1

onuses of tha aeparation, 139
Fractare of patella, recant.

aymploms, 1+1

prognosia, 142

anchylosis, 142

treHlment, 146
sprain of the oailns, 154
dure of loner end of radius

See Consolidation.

eOI'OREl. (EM. nrthrlllB of knee, 2M
Gu^rin'a cotton ilr^aaing. 26<;
Gunshot wounds, 231), 255, 200, 268

INDEX.

849

HAND, abscess of, 828
Heberden's nodosities, 325
Hennequin's apparatus for fracture of

thigh, 165
Hip, dislocation of, 282
Hydrarthrosis, 299
prognosis, 801
treatment, 802
Hyperostosis, 89, 126

associated with necrosis, 218
its indication in arthritis, 295
of patella, in chronic arthritis, 801

IMMOBILITY, a cause of anchylosis, 295
Immovable bandages, 88
Impaction in fracture, 122, 172, 178, 185
Ingrown toe-nail, 1
origin, 8
prophylaxis, 3
treatment, 6
Iterative fracture of thigh, 168

NEE, acute gonorrhoea! arthritis, 290
anchylosis, 89, 295
contusion and sprain, 286
penetrating wound of, 284
subacute, non-suppurating epiphysary

osteitis, 81
suppurating arthritis, 45

T ISTER'S dressing, 272

MALGAIGNE'S hooks for patella, 148
Malgaigne's point, 96
Mechanical bed, 82

VTASO-PHARYNGEAL fibrous polyp, 18
li influence of age and sex, 19

statistics of operations, 21

palliative operation, 28

paralysis and exophthalmia in, 28

treatment, 28
Necrosis, etiology, 218

in long and short bones, 222
Neuralgia after fracture, 127

OSTEITIS, acute epiphysary of youth,
statistics of age of patients, 87
causing hyperostosis of femur, and

anchylosis of knee, 89
pathology, 40
of lower end of tibia, 41
causing necrosis, 42
prognosis, 48
treatment, 44
of femur with suppurating arthritis of

knee, 45
pathology, 46

Osteitis, synonyms, 47

differences of location, 48

intensity, 49
diagnosis, 50
Osteitis, subacute^ non-suppurating epi-
physary.
of the knee, 81

prognosis, 82
of the great trochanter, 88
chance of suppuration, 36
treatment, 85
Osteitis, condensing, after fracture, 69
Osteitis, its connection with scrofula, 222
spontaneous, 222
etiology, 224
Osteitis, traumatic of long bones, 211

pathology, 212, 214, 216, 220
Osteo- myelitis, 47

after compound fracture, 76, 77, 211
Osteo-myelitis, putrid and diffuse.
1st degree, 218

2d degree, after amputation of thigh,
214
accompanying putrid phlebitis,
215
non -putrid phlebitis, 216

PATELLA, hyperostosis of, its indication
in arthritis, 801
Patella, non-consolidated fracture.

study of movements and functions, 186

study of causes of non-union, 189. See
also Fracture.
Penetrating wound of knee, 284
Periostitis, acute, 49
Phlebitis, in putrid osteo-myelitis, 215, 216

as cause of purulent infection, 242,
246
Phlegmon of forearm, 832

Dolbeau's theory, 335
PhlyctaBua after fracture, 81
Planchette polydactyle, 86
Plaster splints, 87

bandage, 88
Polyp, clinical meaning, 20. See Naso-pha-

ryngeal.
Porte-ligature of Hatin, 29
Pseudarthrosis, 138, 191

operation to relieve, 185
Purulent infection, 216, 236

autopsies, 236

etiology, 241

author's theory, 248

anatomical causes, 254

general causes, 254

treatment, 260. See also Septicaemia.
Pyaemia, 236. See Purulent infection and
Septicaemia.

RADIUS, fracture of, 198-205. See Frac-
ture.
Rarefaction, senile, of bone, 189, 201
Rheumatic arthritis, 825

850

INDEX.

SCROFULA, its relation to osteitis, 222
Scultet's apparatus for treatment of
fracture, 86
Septicasmia, 212, 231
etiology, 282, 248
anatomical causes, 254
general causes, 264
treatment and prophylaxis, 260
by immediate union, 268
infrequent dressing, 266
Gu^rin's dressing, 266
pneumatic occlusion, 271
disinfecting dressings, 272
SepticsBmia, bastard, 828
Sequestrum, method of search, 228

removal, 228
Shortening after fracture, 78
Shoulder, dislocation, 277
Silicated bandage, 89
Splenization of bone, 808
Synovial sac of fingers, 829
Synovitis, after fracture, 70, 74
of flexors of the fingers, 828

TARSALGIA of adolescents, 51
1st degree, history and symptoms, 51
autopsy, 53
etiology, 54
course, 56
treatment, 57

Tarsalgia, 2d degree, 58

Duchenne*s theory, 55, 59

8d and 4th degrees, 60
Tendo Achillis, its division after fracture of

leg, 100
Toe-nail, ingrown, 1. See Ingrown.
Traumatic fever, intense.

autopsy, 212

course, 228

forerunner of suppuration, 229

synonyms, 229 .

experiments to discover cause, 280

etiology, 284

treatment, 286, 260

Y-SHAPED fractures, 90. See Fracture
of leg.
Veins, in pyaemia and osteo-myelitis, 216,
216, 241
obliteration of, after fracture, 70, 131
Vertebra, exostosis of 7th cervical, 16

HITE swelling, 804. See Fungoid ar
thritis.

OUTH, diseases of, definition, 37

• * '

J ■"":-'■ ,. . i

1 G-LsiBWOnsMEinaureRiW

^^P LANE MEDICAL LIBRARY

^K To avoid Hnc, this booh sbould be returned oa
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G67e Clinical lectures on *

D^^TE bUE

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_._. ._.: 7^

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